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Intimate Partner Violence: Perspectives on Universal Screening for Women in VHA Primary Care

Open AccessPublished:February 15, 2013DOI:https://doi.org/10.1016/j.whi.2012.12.004
      Intimate partner violence (IPV) poses a significant threat to public health and safety, particularly for women, in the United States. IPV can be defined as physical violence, sexual violence, threats of physical or sexual violence, and stalking and psychological aggression (including coercive tactics) by a current or former intimate partner (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • et al.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report.
      ). Epidemiological studies in the general population suggest that one in three women experiences IPV during her lifetime (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • et al.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report.
      ); nearly equivalent rates (33%) of lifetime IPV exposure have been reported among female veterans (
      • Dichter M.E.
      • Cerulli C.
      • Bossarte R.M.
      Intimate partner violence victimization among women veterans and associated heart health risks.
      ;
      • Murdoch M.
      • Nichol K.L.
      Women veterans’ experiences with domestic violence and with sexual harassment while in the military.
      ). There are currently 1.8 million female veterans in the United States (

      Department of Veterans Affairs (2007). Veteran population projection model (VetPop07). Retrieved from http://www.va.gov/.

      ). Women veterans using Veterans Health Administration (VHA) facilities for their health and mental health care often demonstrate diminished physical and mental health relative to their civilian peers; this difference in health status is attributed, at least in part, to women veterans' greater exposure to trauma (
      • Dobie D.J.
      • Kivlahan D.R.
      • Maynard C.
      • Bush K.R.
      • Davis T.M.
      • Bradley K.A.
      Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment.
      ;
      • Fontana A.
      • Rosenheck R.
      Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment.
      ;
      • Frayne S.M.
      • Seaver M.R.
      • Loveland S.
      • Christiansen C.L.
      • Spiro A.
      • Parker V.A.
      • et al.
      Burden of medical illness in women with depression and posttraumatic stress disorder.
      ;
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ). IPV exposure may be an underappreciated factor contributing to the relatively poorer physical and mental health outcomes for women veterans (
      • Murdoch M.
      • Nichol K.L.
      Women veterans’ experiences with domestic violence and with sexual harassment while in the military.
      ).
      Recent estimates suggest that 7 million U.S. women are victimized by their intimate partners each year (
      • Black M.C.
      • Basile K.C.
      • Breiding M.J.
      • Smith S.G.
      • Walters M.L.
      • Merrick M.T.
      • et al.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report.
      ). The medical and mental health sequelae of IPV victimization are manifold. Specifically, more than 1,000 U.S. women die each year as a result of physical assault from husbands or boyfriends (

      Catalano, S. (2007). Intimate partner violence in the United States. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics. Retrieved from http://www.ojp.usdoj.gov/.

      ). Moreover, the significant medical sequelae of IPV can include acute soft tissue injuries, fractures, joint dislocation, complications associated with anoxia (i.e., from strangulation), and traumatic brain injury (
      • Corrigan J.D.
      • Wolfe M.
      • Mysiw W.J.
      • Jackson R.D.
      • Bogner J.A.
      Early identification of mild traumatic brain injury in female victims of domestic violence.
      ;
      • Sheridan D.J.
      • Nash K.R.
      Acute injury patterns of intimate partner violence victims.
      ). Further, IPV has been associated with chronic health conditions such as musculoskeletal and genitourinary disorders (
      • Bonomi A.E.
      • Anderson M.L.
      • Reid R.J.
      • Rivara F.P.
      • Carrell D.
      • Thompson R.S.
      Medical and psychosocial diagnoses in women with a history of intimate partner violence.
      ;
      • Ellsberg M.
      • Jansen H.M.
      • Heise L.
      • Watts C.H.
      • García-Moreno C.
      Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study.
      ;
      • Leserman J.
      • Li Z.Z.
      • Drossman D.A.
      • Hu Y.B.
      Selected symptoms associated with sexual and physical abuse history among female patients with gastrointestinal disorders: The impact on subsequent health care visits.
      ). Because IPV commonly includes sexual assault or abuse, risk for sexual health problems, including sexually transmitted infection (including HIV), and unintended pregnancy, is heightened among women with IPV exposure (
      • American College of Obstetricians and Gynecologists
      Committee on Healthcare for Underserved Women, Committee Opinion: Intimate Partner Violence, 518.
      ;
      • Bauer H.M.
      • Gibson P.
      • Hernandez M.
      • Kent C.
      • Klausner J.
      • Bolan G.
      Intimate partner violence and high-risk sexual behaviors among female patients with sexually transmitted diseases.
      ;
      • Campbell J.C.
      • Baty M.L.
      • Ghandour R.M.
      • Stockman J.K.
      • Francisco L.
      • Wagman J.
      The intersection of intimate partner violence against women and HIV/AIDS: A review.
      ;
      • Hess K.L.
      • Javanbakht M.
      • Brown J.M.
      • Weiss R.E.
      • Hsu P.
      • Gorbach P.M.
      Intimate partner violence and sexually transmitted infections among young adult women.
      ;
      • Mittal M.
      • Senn T.E.
      • Carey M.P.
      Mediators of the relation between partner violence and sexual risk behavior among women attending a sexually transmitted disease clinic.
      ;
      • Russell M.
      • Chen M.J.
      • Nochajski T.H.
      • Testa M.
      • Zimmerman S.J.
      • Hughes P.S.
      Risky sexual behavior, bleeding caused by intimate partner violence, and hepatitis C virus infection in patients of a sexually transmitted disease clinic.
      ;
      • Senn T.E.
      • Carey M.P.
      • Vanable P.A.
      The intersection of violence, substance use, depression, and STDs: Testing of a syndemic pattern among patients attending an urban STD clinic.
      ;
      • Seth P.
      • Raiford J.L.
      • Robinson L.S.
      • Wingood G.M.
      • Diclemente R.J.
      Intimate partner violence and other partner-related factors: correlates of sexually transmissible infections and risky sexual behaviours among young adult African American women.
      ).
      IPV has also been linked to other deleterious mental health consequences including increased rates of suicide attempts, sleep disturbances, problematic substance use, and ineffective coping (
      • Becker K.D.
      • Stuewig J.
      • McCloskey L.A.
      Traumatic stress symptoms of women exposed to different forms of childhood victimization and intimate partner violence.
      ;
      • Bonomi A.E.
      • Anderson M.L.
      • Reid R.J.
      • Rivara F.P.
      • Carrell D.
      • Thompson R.S.
      Medical and psychosocial diagnoses in women with a history of intimate partner violence.
      ;
      • Cavanaugh C.E.
      • Messing J.
      • Del-Colle M.
      • O’Sullivan C.
      • Campbell J.C.
      Prevalence and correlates of suicidal behavior among adult female victims of intimate partner violence.
      ;
      • Dichter M.E.
      • Cerulli C.
      • Bossarte R.M.
      Intimate partner violence victimization among women veterans and associated heart health risks.
      ;
      • Ellsberg M.
      • Jansen H.M.
      • Heise L.
      • Watts C.H.
      • García-Moreno C.
      Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: An observational study.
      ;
      • Linton S.
      • Larden M.
      • Gillow A.
      Sexual abuse and chronic musculoskeletal pain: Prevalence and psychological factors.
      ;
      • Nicolaidis C.
      • Curry M.
      • McFarland B.
      • Gerrity M.
      Violence, mental health, and physical symptoms in an academic internal medicine practice.
      ). IPV exposure has also been linked with the development of several mental health conditions including posttraumatic stress disorder (PTSD) and depression (
      • Campbell J.C.
      • Lewandowski L.A.
      Mental and physical health effects of intimate partner violence on women and children.
      ;
      • Coker A.L.
      • Weston R.
      • Creson D.L.
      • Justice B.
      • Blakeney P.
      PTSD symptoms among men and women survivors of intimate partner violence: The role of risk and protective factors.
      ;
      • Pico-Alfonso M.A.
      • Garcia-Linares M.
      • Celda-Navarro N.
      • Blasco-Ros C.
      • Echeburúa E.
      • Martinez M.
      The impact of physical, psychological, and sexual intimate male partner violence on women's mental health: Depressive symptoms, posttraumatic stress disorder, state anxiety, and suicide.
      ;
      • Golding J.M.
      Intimate partner violence as a risk factor for mental disorders: A meta-analysis.
      ;
      • Nathanson A.M.
      • Shorey R.C.
      • Tirone V.
      • Rhatigan D.L.
      The prevalence of mental health disorders in a community sample of female victims of intimate partner violence.
      ) that are common among female veterans (
      • Fontana A.
      • Rosenheck R.
      Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment.
      ).
      The significant prevalence of IPV exposure among female veterans coupled with its serious implications for their health and well-being suggests a strong need for the development of a standard, universal screening program designed to detect IPV risk among women seeking services within VHA. As the largest integrated health care system in the United States, VHA is a leader in quality and innovation and boasts a fully implemented electronic medical record system. The VHA provides medical and mental health services to approximately 8.6 million veterans each year, 6% (about 500,000) of whom are female (
      • Frayne S.M.
      • Phibbs C.S.
      • Friedman S.A.
      • Berg E.
      • Ananth L.
      • Iqbal S.
      • Herrera L.
      • et al.
      Sourcebook: Women veterans in the Veterans Health Administration. Volume 1. Sociodemographic characteristics and use of VHA Care.
      ;

      Department of Veterans Affairs (2007). Veteran population projection model (VetPop07). Retrieved from http://www.va.gov/.

      ). The development an IPV screening program in VHA may be particularly timely given the rapidly growing and changing demographics of the female veteran population. These changes include increasing rates of pregnancy among younger women veterans (
      • Goyal V.
      • Borrero S.
      • Schwartz E.B.
      Unintended pregnancy and contraception among active-duty servicewomen and veterans.
      ;
      • Holt K.
      • Grindlay K.
      • Taskier M.
      • Grossman D.
      Unintended pregnancy and contraceptive use among women in the U.S. military: A systematic literature review.
      ;
      • Yoon J.
      • Scott J.Y.
      • Phibbs C.S.
      • Frayne S.M.
      Trends in rates and attributable costs of conditions among female VA patients, 2000 and 2008.
      ), which increases risk for IPV exposure (
      • Brownridge D.A.
      • Taillieu T.L.
      • Tyler K.A.
      • Tiwari A.
      • Chan K.
      • Santos S.C.
      Pregnancy and intimate partner violence: Risk factors, severity, and health effects.
      ;
      • Devries K.M.
      • Kishor S.
      • Johnson H.
      • Stöckl H.
      • Bacchus L.J.
      • Garcia-Moreno C.
      • et al.
      Intimate partner violence during pregnancy: Analysis of prevalence data from 19 countries.
      ), and increasing concerns about the risk of IPV among service members recently returned from Iraq or Afghanistan (
      • Fraser C.
      Family issues associated with military deployment, family violence, and military sexual trauma.
      ;
      • Marshall A.D.
      • Panuzio J.
      • Taft C.T.
      Intimate partner violence among military veterans and active duty servicemen.
      ;
      • Sayers S.L.
      • Farrow V.A.
      • Ross J.
      • Oslin D.W.
      Family problems among recently returned military veterans referred for a mental health evaluation.
      ; Teten, Schumacher, Bailey, & Kent, 2009), particularly those whose male partners have PTSD (
      • Teten A.L.
      • Schumacher J.A.
      • Taft C.T.
      • Stanley M.A.
      • Kent T.A.
      • Bailey S.D.
      • et al.
      Intimate partner aggression perpetrated and sustained by male Afghanistan, Iraq, and Vietnam veterans with and without posttraumatic stress disorder.
      ).
      Successful IPV screening must incorporate mechanisms for appropriate and comprehensive responses to positive screens. This may include coordination of primary care, mental health, social work, and legal services. The VHA has successful models of integrated care and universal screening for other health conditions and exposures. In recognition that primary care visits provide the opportunity to assess for unrecognized disease, VHA already has mechanisms in place to routinely screen for mental health conditions in men and women using well-validated measures such as the Patient Health Questionnaire for depression (
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.W.
      The Patient Health Questionnaire-2: Validity of a two-item depression screener.
      ), the Primary Care-PTSD Screen for PTSD (
      • Prins A.
      • Ouimette P.
      • Kimerling R.
      • Cameron R.P.
      • Hugelshofer D.S.
      • Shaw-Hegwer J.
      • et al.
      The primary care PTSD screen (PC-PTSD): Development and operating characteristics.
      ), and the Alcohol Use Disorders Identification Test for alcohol use disorders (
      • Bradley K.A.
      • DeBenedetti A.F.
      • Volk R.J.
      • Williams E.C.
      • Frank D.
      • Kivlahan D.R.
      AUDIT-C as a brief screen for alcohol misuse in primary care.
      ). The VHA also routinely screens for other trauma exposures, such as military sexual trauma, that may increase risk for subsequent mental health conditions (
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ). The VHA's military sexual trauma screening is one of the first comprehensive health policy responses to sexual trauma in the country, and has resulted in a two-fold increase in likelihood of engagement in mental health treatment among veterans who screened positive compared with those who screened negative (
      • Kimerling R.
      • Street A.E.
      • Gima K.
      • Smith M.W.
      Evaluation of universal screening for military-related sexual trauma.
      ). Screening procedures in VHA are also enhanced owing to the use of an electronic medical record system, which has been shown to improve screening quality (
      • Van Cleave J.
      • Kuhlthau K.A.
      • Bloom S.
      • Newacheck P.W.
      • Nozzolillo A.A.
      • Homer C.J.
      • et al.
      Interventions to improve screening and follow-up in primary care: A systematic review of the evidence.
      ). In 2007 and 2008, the VHA underwent major initiatives to foster Primary Care-Mental Health Integration, resulting in improved detection of mental health diagnoses among primary care patients (
      • Zivin K.
      • Pfeiffer P.N.
      • Szymanski B.R.
      • Valenstein M.
      • Post E.P.
      • Miller E.M.
      • et al.
      Initiation of Primary Care-Mental Health Integration programs in the VA health system: Associations with psychiatric diagnoses in primary care.
      ), treatment of mental health conditions in the primary care setting, and increased engagement in specialty mental health care (
      • Wray L.O.
      • Szymanski B.R.
      • Kearney L.K.
      • McCarthy J.F.
      Implementation of primary care-mental health integration services in the Veterans Health Administration: Program activity and associations with engagement in specialty mental health services.
      ). The Primary Care-Mental Health Integration initiative has resulted in several programs, including Translating Initiatives for Depression into Effective Solutions, focused on collaborative care for depression in primary care, which has demonstrated high levels of treatment engagement in veterans presenting with depression in primary care (
      • Felker B.L.
      • Chaney E.
      • Rubern L.V.
      • Bonner L.M.
      • Yano E.M.
      • Parker L.E.
      • et al.
      Developing effective collaboration between primary care and mental health providers.
      ). Additionally, a clinical service, known as a Behavioral Health Laboratory (BHL), has been implemented in numerous VA medical centers. The mission of the BHLs is to provide comprehensive psychosocial assessments (with efficient, same-day feedback summaries provided to each patient's clinician) for VHA patients in need of mental health care during primary care visits (
      • Oslin D.W.
      • Ross J.
      • Sayers S.
      • Murphy J.
      • Kane V.
      • Katz I.R.
      Screening, assessment, and management of depression in VA primary care clinics: The Behavioral Health Laboratory.
      ). The BHLs have increased the detection of problematic substance use and suicidal ideation, symptoms which may have been missed in routine clinical practice, among veterans using VHA primary care services (
      • Oslin D.W.
      • Ross J.
      • Sayers S.
      • Murphy J.
      • Kane V.
      • Katz I.R.
      Screening, assessment, and management of depression in VA primary care clinics: The Behavioral Health Laboratory.
      ). These existing and successful screening procedures and integrated care models make VHA primary care better equipped than perhaps any other healthcare system to implement universal IPV screening.
      Recognizing the potential benefits for patients, several national health care and advocacy groups and policies, such as the American College of Obstetricians and Gynecologists (2012), the

      Institute of Medicine (2011). Clinical preventive services for women: Closing the gap. Retrieved from http://www.iom.edu/.

      , the Patient Protection and Affordable Care Act (

      H.R. 3590–111th Congress: Patient Protection and Affordable Care Act. Text as of Mar 23, 2010 (Passed Congress/Enrolled Bill). 2009-2010. Retrieved July 6, 2012, from http://www.govtrack.us/.

      ), and Futures Without Violence (
      • Family Violence Prevention Fund
      National consensus guidelines on identifying and responding to domestic violence victimization in health care settings.
      ) advocate for universal IPV screening for women. In addition, the feasibility of implementing universal IPV screening programs within large, managed health care systems has been demonstrated through Kaiser Permanente's successful screening program (
      • McCaw B.
      Using a systems-model approach to Improving IPV services in a large health care organization. In: Preventing violence against women and children: Workshop summary.
      ;
      • McCaw B.
      • Kotz K.
      Intimate partner violence: A health-based perspective.
      ;
      • McCaw B.
      • Berman B.
      • Syme L.
      • Hunkeler E.
      Beyond screening: A systems model approach to domestic violence services in a managed care setting.
      ). Nevertheless, the VHA currently has no systematic program in place to identify patients' exposed to IPV. This reflects, at least in part, the linkage between VHA preventive health screening practices and guidance from the United States Preventive Services Task Force (USPSTF). Citing the poor quality and limited scope of the extant empirical literature on the utility of IPV-related screening, the USPSTF has historically viewed the available evidence on benefits and harms associated with IPV-related screening as inconclusive, offering a “C” grade for the quality of evidence supporting this practice (
      • U.S. Preventive Services Task Force USPSTF
      Screening for family and intimate partner violence: Recommendation statement.
      ;
      • Nelson H.D.
      • Nygren P.
      • McInerney Y.
      • Klein J.
      Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U. S. Preventive Services Task Force.
      ).
      Because the empirical evidence base supporting the utility of screening for IPV has historically been methodologically compromised as well as limited in scope and breadth, it is not surprising that health care environments, such as VHA, have not fully embraced universal screening practices. However, because USPSTF recently upgraded its recommendation for universal IPV screening to a “B” grade, this will inevitably change (
      • U.S. Preventive Services Task Force (USPSTF)
      Screening for intimate partner violence and abuse of elderly and vulnerable adults: Draft recommendation statement.
      ) Specifically, the 2012 USPSTF draft recommendations (
      • U.S. Preventive Services Task Force (USPSTF)
      Screening for intimate partner violence and abuse of elderly and vulnerable adults: Draft recommendation statement.
      ) now encourage primary care clinicians to screen all women of childbearing age (14–46 years, representing 42% of the female veteran population) for IPV and provide or refer women to intervention services when they screen positive. This recommendation for universal screening includes women who do not demonstrate signs or symptoms of abuse. Although this change indirectly reflects the existence of a somewhat larger and methodologically stronger literature base (
      • Nelson H.D.
      • Bougatsos C.
      • Blazina I.
      Screening women for intimate partner violence and elderly and vulnerable adults for abuse: Systematic review to update the 2004 U.S. Preventive Services Task Force recommendation. Evidence Syntheses, No. 92.
      ), it is also linked to increased awareness that the creation of a traditional, empirical evidence base on this issue may not be possible. IPV is not a disease that can be isolated and easily studied with traditional epidemiological methods. Expectations for amassing a traditional evidence base have been replaced with an arguably more realistic perspective and nuanced appreciation that a) failure to screen women for IPV related risks dramatically reduces the likelihood of early identification and intervention, and b) eclipses the potential to study and refine best practices associated with screening.
      The changing guidelines of the USPSTF are expected to influence practice within VHA. We now sit at the verge of the adoption of a new practice that may offer unprecedented benefits to female veterans, including opportunities for critical safety intervention, validation of a high prevalence concern, as well as the development of long-term treatment planning for ongoing medical and mental health needs stemming from IPV exposure. Additionally, VHA will have the opportunity to implement a comprehensive and inclusive behavioral health screening in primary care (e.g. depression, substance use, PTSD, IPV) providing a platform for the development of both short- and long-term treatments for the sequelae of IPV exposure. However, the challenge lies in remaining committed to evidence-based practice. Specifically, with the commencement of systematic screening for IPV exposure, the VHA will need to systematically prepare its workforce to effectively identify and address unforeseen potential complications of screening—for example, those potentially introduced in circumstances where providers may treat both perpetrator and victim. It is also imperative that VHA systematically evaluate and address potential risks of screening within VHA that are not present in non-VA settings. For example, if a veteran's medical or mental health problems were inaccurately attributed exclusively to nonmilitary traumatic experiences appearing in the medical record, that could result in an unjust determination in a review for service-connected benefits.
      In conclusion, the changing USPSTF recommendations for universal IPV screening among women of childbearing age provides the VHA with the opportunity to be at the forefront of developing an efficacious and systematic program to detect and treat consequences stemming from this highly prevalent health threat. There is the potential not only to increase prevention, detection, and treatment of victimization among female veterans but also to begin to address IPV in male veterans, a population at high risk for both IPV perpetration and victimization (
      • Marshall A.D.
      • Panuzio J.
      • Taft C.T.
      Intimate partner violence among military veterans and active duty servicemen.
      ;
      • Taft C.T.
      • Weatherill R.P.
      • Woodward H.E.
      • Pinto L.A.
      • Watkins L.E.
      • Miller M.W.
      • et al.
      Intimate partner and general aggression perpetration among combat veterans presenting to a posttraumatic stress disorder clinic.
      ;
      • Teten A.L.
      • Sherman M.D.
      • Han X.
      Violence between therapy-seeking veterans and their partners: Prevalence and characteristics of nonviolent, mutually violent, and one-sided violent couples.
      ). The potential unknown risks and benefits of IPV screening in VHA call for implementation of universal screening to be accompanied by rigorous evaluation. VHA has a unique ability to longitudinally study the effects of implementing a universal IPV screening protocol owing its national, integrated healthcare system that encompasses a variety of practice settings, both urban and rural. VHA's unique qualities mean that it can play an integral role in informing, revising and improving best practices for IPV screening.

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      Biography

      Alison C. Sweeney, PsyD, is a staff psychologist with the Primary Care - Mental Health Integration Team in the Women's Health Center at the Michael E. DeBakey VA Medical Center. Her research interests include trauma exposure among female veterans and women's reproductive health.

      Biography

      Julie C. Weitlauf, PhD, is a staff psychologist in the Sierra Pacific Mental Illness, Research, Education and Clinical Center of the VA Palo Alto Health Care System and Clinical Associate Professor (Affiliated) of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Her program of research focuses on the effects of physical and sexual violence on women veterans' physical and mental health.

      Biography

      Elizabeth A. Manning, PhD, is a staff psychologist in the Women's Health Center at VA Palo Alto Health Care System. Her research interests include intimate partner violence screening in the female Veteran population and the health impact of trauma exposure in female veterans.

      Biography

      Jocelyn A. Sze, PhD, is in private practice in San Francisco, CA and conducts research with collaborators at SFVAMC, UC Berkeley, and UCSF. Her research interests include emotion and aging, women's health and trauma, and technology-assisted psychotherapy interventions.

      Biography

      Angela E. Waldrop, PhD, is a staff psychologist with the PTSD Clinical Team at the San Francisco VA Medical Center and an Assistant Professor of Psychiatry at the University of California, San Francisco. Her research focuses on decision making and risk taking, with a special focus on co-occurring PTSD and substance use disorders.

      Biography

      Caitlin Hasser, MD, is the director of the Women's Mental Health Program at the San Francisco VA Medical Center and an Assistant Clinical Professor in the Department of Psychiatry at the University of California, San Francisco School of Medicine. Her interests include sexual trauma, intimate partner violence, integration of primary care and mental health and multidisciplinary teaching.