Sexual and Intimate Partner Violence Amongst the Choctaw, a Native American Tribe

In the past month I was called to testify in a United States [criminal] federal court case as a witness regarding a sexual assault case against a Native American female which occurred three years ago. I had been the attending physician in the Emergency Department when a patient came through with an allegation of violent sexual assault. It made me reflect upon a press release which I had heard from the White House several years ago which stated that greater than one in three Native American women are subject to sexual violence in their lifetime, when the US average is less than one in five (Tjaden and Thonennes, 2000). This data comes from a 2005 CDC study which demonstrated that the prevalence of intimate partner violence(IPV) and sexual assault was 39% in Native American women, which is the highest rate of violence seen in any American cohort (Black and Breiding, 2008).

An ecological model can help us to identify factors which relate to the rate of sexual violence, as well as areas to address in terms of prevention. There are four elements to address in the ecological model: Individual, Relationship, Community and Society.

Individual factors include biologic factors as well as attitudes and beliefs which are related to becoming a victim, or a perpetrator of IPV. We know that Native Americans with a history of alcohol use disorder or childhood adverse experiences are at much higher risk. (Yuan, 2006). Alcohol and other substance use disorders are related to both becoming a victim of sexual assault AND is a factor in perpetrators as well (Perry, 2004). Fully 2/3 of Native American victims of sexual violence report their attackers were intoxicated by alcohol and/or drugs (Bachman and Zaykoski et al, 2008). In addition, two other important factors include antisocial personality or latent hostility towards women, and adverse childhood experiences. (Dahlberg and Krug, 2002). It should be noted that adverse childhood experiences are strongly and positively associated with sexual offending. (Delisi et al, 2017). Strangely, married women are also more likely to be victims of sexual assault than non-married tribal members (Yuan, 2006). This is most likely because of the victim being trapped with an abuser (sometimes with a substance use disorder) and not having a strong enough family/community structure to escape the violence.

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Relationship factors are factors that increase risk of victimization or perpetration of violence through interaction with family members, sexual partners or associates. Families which have poor emotional supports and increased adverse childhood experiences are associated with increased victimization rates (Delisi et al, 2017). Additionally, many Native American relationships are complicated by polysubstance use disorder which is a known risk factor for interpartner violence, and fully 2/3 of victims of sexual violence report their attackers were intoxicated by alcohol and/or drugs (Bachman and Zaykoski et al, 2008).

Community factors looks at the settings in which sexual assaults occur. Choctaw is a rural community, so policing is more difficult than an urban setting. In terms of prosecution of offenders, the ‘Violence Against Women Act’ of 2013 allows Native American tribes to prosecute non-tribal members for intimate partner violence, but not for rape or sexual assault. Resources have become more available for victim on the Choctaw Reservation such as Family Violence and Victim Services center (established in 1999), and the Domestic Violence Shelter, established in 2012.

Finally, societal factors include large social factors that encourage or inhibit sexual violence. The Choctaw had a ‘trail of tears’ in the 1831-33, and the majority of the Mississippi tribe, approximately 12,500 Natives, were rounded up and moved over 700 miles away to Oklahoma, and territories west of the Mississippi river (Shultz and Walter, 2016). Estimates vary from 1,500 to 4,000, but many thousands of Choctaw died (Bunbury, 2016). The remaining Native Americans who stayed in Mississippi had effectively hid in the swamps of the middle of the state where they encountered significant harassment from the new European settlers in the 1830’s and 1840’s (Bunbury, 2016). This enabled their survival and their ability to live and stay in Mississippi, but there are social consequences from their harsh treatment. The effects of this filter down to the community through poverty, now at 23.1% of families (US Census Bureau, 2016), and a reticence to call the police for suspected cases of sexual assault(Detels, Guilliford et al, 2015). In fact, health information is the notoriously difficult to collect due to resistance on her part of the native people to speak with outsiders and especially authority figures (Detels, Guilliford et al, 2015).

A Health Inequity Analysis Tool (HEAT) can help to better understand the reasons for the increased prevalence of sexual assault and intimate partner violence amongst NA tribal women.

A study by Maloe, Duran and Montgomery (2004) noted that 26% of native Americans are living in poverty versus only 13% of the overall US population and 10% of caucasians. The reasons for the elevated poverty rates are complex, but are in part due to the colonial nature of the United States treatment and devaluation of Native Americans (Braveheart and DeBruyn, 1998). There exists some evidence that tribal members in the lowest socioeconomic strata are at increased risk. It has been noted in table 4 of the Maloe, Duran and Montgomery (2004) that in a study of 312 trial members who had been subjected to intimate partner violence (IPV) in Oklahoma, USA that poverty level was a key inequalities present and related to the rate of IPV. Study members who were living in poverty at less than 50% of the poverty wage graduating high school had a victimization rate in the prior year of 33.3% vs 16.7% of those who were not living in poverty.

Overall, the rate of sexual assault for Native American women is 5/1000 per year versus 2/1000 in the general United States population (Perry, 2004). Bisexual women have an increased risk for intimate partner violence, at 56.9 % lifetime prevalence rate versus 32.3% in heterosexual woman (Brown and Herman, 2015). There are no studies which have investigated the reasons why bisexual Native Americans are at such demonstrably increased risk for IPV.

In terms of geographic distribution of IPV amongst Native American tribes, the scientific literature is replete with small trials demonstrating prevalence of IPV in particular areas. Though there are different assault rates amongst the different tribes, there are no clear trends in the data. Within 8 tribes in California, a prelevance of lifetime sexual abuse was found to be 34%. (Ehlers et al, 2013) However, within the Indian Health Service, lifetime prevalence for sexual assault was found to be only 12% in patients seeking general primary care (Fairchild et al, 1998).

A strong risk factor for sexual assault of Native Americans is any lifetime history of alcohol use disorder, formerly known as alcohol dependance (Yuan, 2006). Further, amongst sexual assault victims, 68% stated the alleged assailant was under the influence of alcohol and/or drugs (Perry, 2004).

The reasons for the increased prevalence of intimate partner violence and sexual assaults of Native Americans are multi-factorial and complex. There is a need for further research into health inequities, and this may further elucidate ways in which the problem could be alleviated. Certainly, further assistance with substance abuse and helping Native Americans out of poverty would all be positive measures to help alleviate the problem.

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Health Inequity Analysis Tool:

 1) What Inequities Exist? 2)Who’s most advantaged? 3) How did inequity occur?

Socioeconomic:  Poverty Within NA Higher SES women Class society (Maloe et al, 2004)

Ethnic: Highest rates in NA Caucasians Substance use rate inequality (Yuan, 2006)

Gender: Female>Male (Perry, 2004) Males Unclear from data, but can readily

        hypothesize that physical strength plays a

 role

Sexual orientation: Bisexual > heterosexual Heterosexual men  Unclear from data (Brown & Herman, 2013)

 (Bachman and Zaykoski et al, 2008)

Geographic: Differs amongst tribes Those off reservation  (Ehlers et al, 2013)

Disability: Alcohol dependance   Abstainers are more advantaged (Yuan, 2006) 

in victims of sexual assault.

   Alcohol/drug use in alleged assailants. (Perry, 2004)

Age:   Young > Old (Perry, 2004)

Other:   Marriage and Hx of Childhood maltreatment are risk factors for physical and sexual assault

amongst Native Americans (Yuan, 2006).

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A stakeholder analysis can help to identify according to the article by Dearden with the Department for International Development (2013). Please see Figure 1 for a synopsis of the importance/influence matrix.

The key stakeholders include the victims of sexual assault and IPV, as well as their families and children. However, these people have low influence in terms of remedying the problem. Bisexual tribal members, and women who have alcohol use disorder are at higher risk (Bachman and Zaykoski et al, 2008).

Figure 1:

High importance/low influence

Native females living in poverty

Female tribal members who have alcohol use disorders

Bisexual Native women 

Drug/Alcohol users who perform intimate partner violence and sexual assault

High importance/high influence 

Tribal courts

Tribal social service and community health coordinators

Office of the Tribal Chief

Police officers 

Sexual assault nurse evaluators 

Physicians

Family violence/victim services program

Substance Use evaluation and treatment programs

Low importance/low influence

Allied healthcare staff of hospital

Schools 

Non-tribal social services

Families and Children of the victim

Low importance/high influence

Media outlets

American Medical Association

National Organization for Women

Further key stakeholders include the Office of the Tribal Chief, the Tribal Courts and community health coordinators. With buy-in from the Tribal Chief, funding and political impediments will be much less likely. In addition, the recent Choctaw Chief is the first female Chief in modern times (since the tribe was officially recognized by the US Federal government in 1948).

For many years IPV was underreported and under-prosecuted by the Choctaw Tribe. In recent years, better assessment of the prevalence of the problem is becoming possible. The development of a Family Violence/Victim’s Services (FVVS) department in 1999 in conjunction with a domestic violence victim’s shelter in 2012 have showed the type of engagement and commitment the Choctaw leadership have for this problem. However, data is still not published in the literature on the actual rates of sexual assault and IPV within the Choctaw tribe. 

Further key stakeholders include primary care physicians and Sexual assault nurse evaluators (SANE). These people are on the front line in the medical evaluation and management of the situation. Their engagement would be vital in implementing IPV initiatives. A study by Miller and McCaw et al. (2015) has demonstrated that EHR assisted screening for physicians leads to better assessments of prevalence, and physician referral of IPV victims to FVVS leads to better adherence with follow-up. It has also be shown by a study by Shaples et al. (2018) that having specially trained medical assistants screen for IPV results in higher reports than physician screening alone.

Police officers as also heavily involved in the initial presentation of IPV victims to the healthcare system. In the past domestic violence was tolerated more by US society at large, but this has changed over the past 50 years, and IPV is more often reported and prosecuted (Danis, 2003). However, there is a need for further study of batterer’s intervention programs and alternatives to incarceration. Not all offenders are the same – focusing on their different personality characteristics and the types of violence committed can help to tailor treatment (Aaron and Beaulaurier, 2016). The World Health Organization’s article (2003) entitled ‘Responding to IPV and sexual violence against women’ recommends both legislative changes and media initiatives to increase the awareness of the community to IPV.

References:

Aaron S and Beaulaurier R. (2016). The Need for New Emphasis on Batterers Intervention Programs. Trauma, Violence & Abuse. 18(4):pp425-32.

Bachman R, Zaykowski H et al. (2008). U.S. Department of Justice. Violence Against American Indian and Alaska Native Women and the Criminal Justice Response: What is known. Vol 39. Available online at: https://www.ncjrs.gov/pdffiles1/nij/grants/223691.pdf Accessed 9/23/18.

Black, Breiding et al. (2008). Adverse health conditions and health risk behaviors associated with intimate partner violence – United States, 2005. MMWR 57(5)113-117.

Braveheart MY and Debruyn LM. (1998). The American Indian holocaust: healing unresolved historical grief. Amer Indian Alsk Native Ment Hlth Res 8(2):56-78.

Brown T and Herman JL. (2015). Intimate Partner Violence and Sexual Abuse Among LGBT People – A Review of Existing Research. Williams Institute at UCLA School of Law. Available online: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Intimate-Partner-Violence-and-Sexual-Abuse-among-LGBT-People.pdf Accessed: 10/9/2018.
Centers for Disease Control and Prevention. (2004) Sexual violence prevention: beginning the dialogue. Atlanta, GA: Centers for Disease Control and Prevention. Available online at: https://www.cdc.gov/violenceprevention/pdf/SVPrevention-a.pdf Accessed: 10/24/2018

Dahlberg LL, Krug EG. (2002). Violence-a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization. pp. 1–56. Available at http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html

Danis F. (2003). The Criminalization of Domestic Violence: What Social Workers Need to Know. Social Work. 48(2):pp237-46.

Dearden P et al. (2003). Department for International Development [DFID] “Stakeholder Analysis”, in Tools for Development, A handbook for those engaged in development activity, pp. 2.1-2.12

DeLisi, M., Alcala, J et al. (2017). Adverse Childhood Experiences, Commitment Offense, and Race/Ethnicity: Are the Effects Crime-, Race-, and Ethnicity-Specific? Int. J. Environ. Res. Public Health. (14):331. Available online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5369166/Accessed online: 10/20/2018.

Detels, Guilford et al. (2015). Oxford Texbook of Global Public Health (6th ed): The health of indigenous peoples. Oxford Press. Accessed online 9/26/18.

Ehlers CL, Gizer IR, Gilder DA et al. (2013). Lifetime history of of traumatic events and in an American Indian community sample: heritability and relation to substance dependence, affective disorder, conduct disorder, and PTSD. J Psychiatr Res. 47(2):155-61.

Fairchild DG, Fairchild MW and Stoner S. (1998). Prevalence of adult domestic violence among women seeking routine care in a Native American health care facility. Am J Public Health 88(10): 1515-17.

Malcoe LH, Duran BM, and Montgomery, JM. (2004). Socioeconomic disparities in intimate partner violence against Native American women: a cross-sectional study. BMC Med 24;2:20. Available online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC446227/ Accessed: 10/9/2018.

Miller E, McCaw B et al. (2015). Integrating Intimate Partner Violence Assessment and Intervention into Healthcare in the United States: A Systems Approach. J Womens Hlth 24(1):92-99.

Perry SW. (2004). American Indians and Crime – A BJS Statistical Profile 1992-2002, Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs.

Shaples L, Nguyen C, Singh B et al. (2018). Identifying Opportunities to Improve Intimate Partner Violence Screening in aPrimary Care System. Fam Med. 50(9):702-705.

Schultz K, Walters K et al. (2016). “I’m stronger than I thought“: native women reconnecting to body, health, and place. Health place. July;40:21-8.

Tjaden and Thonennes. (2000). Prevalence, incidence, and consequences of violence against women: findings from the National Violence Survey against Women. National Institute of Justice in the centers for disease control and prevention. Available online at: http//www.ncjrs.gov/txtfiles1/nij/183781.txt Accessed 9/23/2018.

US Census Bureau (2016). / American FactFinder. “Quickfacts Choctaw County, Mississippi – Persons in Poverty, Percent.” Available online: https://www.census.gov/quickfacts/fact/table/choctawcountymississippi#viewtop Accessed: 10/25/2018

Yuan NP. (2006). Risk Factors for Physical Assault and Rape Among Six American Tribes. J Interpersonal Violence. 21(12):1566-1590. https://doi.org/10.1177%2F0886260506294239 Accessed: 10/9/2018.

World Health Organization. (2013). Responding to intimate partner violence and sexual violence against women. http://www.who.int/reproductivehealth/publications/violence /9789241548595/en/ Accessed: 10/20/2018.

Personal Development Plan

What are my priorities? Referring to the “Skill elements” column of Cavanagh and Chadwick (pp 50 – 53), identify at least one that you would like to develop or improve on by doing the MPH. The other(s) could be skills that you would like to develop or improve on either by doing the MPH or independently of your studies (e.g. through your workplace)

Where am I now?

Briefly summarise your current level of knowledge and experience in relation to each of these and why you think it is important to develop further.

Where do I want to get to?

Express these as learning objectives – what specifically do you want to develop or improve on?

How am I going to get there?

Make a plan. What actions might you take to achieve your learning objectives? What support and resources will you need?

How will I know that I have been successful?

It is never enough simply to have a plan – you must also evaluate how successful your plan was.

Project management – Time management

I am currently working 1.5 Full Time equivalents as an Emergency Physician, as well as a spouse, and a Board member of the Amer Board of Urgent Care Med. Time is my most precious resource!

Feeling more comfortable in terms of setting appropriate limits. Better parsing of time between my responsibilities.

Limiting extraneous responsibilities. Multi-tasking (working on assignments at work) as well as when off work; I need more time!

I think my grades will be one reflection of how I’m doing in this endeavor. My anxiety level will be less as I become more comfortable in returning to academia.

Community engagement – reaching marginalized communities

Though I have been working with the Mississippi Band of Choctaw Indians for 10 years, I have not completed a single scientific study. A better understanding of the design of public health studies would give me the confidence to approach the Chief for permission to begin.

I would like to be able to get a public health study designed and ready to initiate by the end of the course, pertinent to the Choctaw Tribe.

Better understanding of the pressing public health needs. What do we need to know?

Is it politically feasible to obtain?

I will be ready to begin a public health study to quantify something unknown amongst the Choctaw Tribe.

I will reach out to politically connected members of the tribe when I am ready to connect with the Chief.

Data Collection – Surveys

It has been said that the hardest part of the study is the set up/methods section.

A rounded public health education will allow me to focus on what needs to be collected and what can be readily analysed.

I would like to be able to get a public health study designed and ready to initiate by the end of the course, pertinent to the Choctaw Tribe.

Careful analysis of the chosen issue, and a strong literature review will be key to development of a proper survey. Hopefully my University of Edinburgh mentor can give me some guidance.

I will be able to have a survey in hand by the end of the course which can help us to better understand a relevant public health issue amongst the Choctaw Tribe.