From Treatment to Healing: The Promise of Trauma-Informed Primary Care

      In August 2013, a national strategy group convened in Washington, DC to clarify a framework for trauma-informed primary care (TIPC) for women. The group was motivated by an increasing body of research and experience revealing that people from all races, ethnicities, and socioeconomic backgrounds come to primary care with common conditions (e.g., heart, lung, and liver diseases, obesity, diabetes, depression, substance use, and sexually transmitted infections) that can be traced to recent and past trauma. These conditions are often stubbornly refractory to treatment, in part because we are not addressing the trauma and posttraumatic stress disorder (PTSD) that underlie and perpetuate them. The purpose of the strategy group was to review the evidence linking trauma to health and provide practical guidance to clinicians, researchers, and policymakers about the core components of an effective response to recent and past trauma in the setting of primary care. We describe the results of this work and advocate for the adoption of TIPC as a practical and ethical imperative for women's health and well-being.
      To read this article in full you will need to make a payment
      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. ACE Study–Health Presentations (2014). Adverse Childhood Experiences Study. Available: Accessed January 28, 2015.

        • American Medical Association
        American Medical Association diagnostic and treatment guidelines on domestic violence.
        Archives of Family Medicine. 1992; 1: 39-47
      2. Agency for Healthcare Research and Quality. (n.d.). Patient-centered medical home resource center: Defining PCMH. Available: Accessed March 14, 2015.

        • Bair-Merritt M.H.
        • Lewis-O'Connor A.
        • Goel S.
        • Amato P.
        • Ismailji T.
        • Jelley M.
        • Cronholm P.
        • et al.
        Primary care-based interventions for intimate partner violence: A systematic review.
        American Journal of Preventive Medicine. 2014; 46: 188-194
        • Black M.C.
        • Basile K.C.
        • Breiding M.J.
        • Smith S.G.
        • Walters M.L.
        • Merrick M.T.
        • Chen J.
        • Stevens M.R.
        The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report.
        Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Atlanta2011
        • Bloom S.
        Creating Sanctuary: Toward the Evolution of Sane Societies (revised edition).
        Taylor & Francis, New York2013
        • Bott S.
        • Guedes A.
        • Claramunt M.C.
        • Guezmes A.
        Improving the Health Sector Response to Gender-Based Violence: A Resource Manual for Health Care Professionals in Developing in Countries.
        International Planned Parenthood Federation / Western Hemisphere Region, New York2004
        • Bowes L.
        • Jaffee S.R.
        Biology, genes, and resilience: Toward a multidisciplinary approach.
        Trauma, Violence, & Abuse. 2013; 14: 195-208
        • Campbell J.C.
        • Webster D.W.
        • Glass N.
        The Danger Assessment: Validation of a lethality risk assessment instrument for intimate partner femicide.
        Journal of Interpersonal Violence. 2009; 24: 653-674
        • Carey T.S.
        • Crotty K.A.
        • Morrissey J.P.
        • Jonas D.E.
        • Viswanathan M.
        • Thaker S.
        • Ellis A.R.
        • Woodell C.
        • Wines C.
        Future research needs for the integration of mental health/substance abuse and primary care: Identification of future research needs from evidence. Report/technology assessment No. 173 Future Research Needs Papers.
        Agency for Healthcare Research and Quality, Rockville, MD2010 (Available:) (Accessed March 24, 2014)
      3. Centers for Disease Control and Prevention Division of Violence Prevention (2014a). Adverse Childhood Experiences Study. Available: Accessed January 28, 2015.

      4. Centers for Disease Control and Prevention Division of Violence Prevention. (2014b). Intimate partner violence. Available: Accessed January 28, 2015.

      5. Cloitre, M., Courtois, C. A., Ford, J. D., Green, B. L., Alexander, P., Briere, J., Herman, J. L., Lanius, R., Stolback, B. C., Spinazzola, J., Van der Kok, B. A., & Van der Hart, O. (2012). The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Available: Accessed March 24, 2014.

        • Community Connections
        Creating cultures of trauma-informed care.
        Community Connections, Washington, DC2009
        • Dawson L.
        • Kates J.
        HIV, intimate partner violence, and women: New opportunities under the Affordable Care Act (ACA).
        in: The Henry J. Kaiser Family Foundation Issue Brief. 2014 (Menlo Park: The Henry J. Kaiser Family Foundation. Available:) (Accessed March 14, 2015)
        • Engel C.C.
        • Oxman T.
        • Yamamoto C.
        • Gould D.
        • Barry S.
        • Stewart P.
        • Dietrich A.J.
        • et al.
        RESPECT-Mil: Feasibility of a systems-level collaborative care approach to depression and post-traumatic stress disorder in military primary care.
        Military Medicine. 2008; 173: 935
        • Forbes A.
        • Bowers M.
        • Langhorne A.
        • Yakovchenko V.
        • Taylor S.
        Bringing it back home: Making gender central in the domestic US AIDS response.
        Women's Health Issues. 2011; 21: S221-S226
      6. Futures Without Violence. (2013). IPV Screening and Counseling Toolkit. Available: Accessed March 12, 2015.

        • García-Moreno C.
        • Hegarty K.
        • d'Oliveira A.F.L.
        • Koziol-MacLain J.
        • Colombini M.
        • Feder G.
        The health-systems response to violence against women.
        Lancet. 2014;
        • Ghandour R.M.
        • Campbell J.C.
        • Lloyd J.
        Screening and counseling for intimate partner violence: A vision for the future.
        Journal of Women's Health. 2014; 24: 57-61
        • Gilbert R.
        • Kemp A.
        • Thoburn J.
        • Sidebotham P.
        • Radford L.
        • Glaser D.
        • Macmillan H.L.
        Recognising and responding to child maltreatment.
        Lancet. 2009; 373: 167-180
      7. Using trauma theory to design service systems. Vol. 89. Jossey-Bass, San Francisco2001
        • Herman J.L.
        Trauma and recovery: The aftermath of violence from domestic abuse to political terror.
        Basic Books, New York1997
        • Institute of Medicine Committee on Preventive Services for Women
        Clinical preventive services for women: Closing the gaps.
        The National Academies Press, Washington, DC2011 (Available:) (Accessed January 16, 2015)
        • Joint Commission on Accreditation of Healthcare Organizations
        How to recognize abuse and neglect.
        Joint Commission Resources, Oak Brook, IL2002
      8. LEAP (2015). LEAP: Look to End Abuse Permanently. Available: Accessed March 13, 2015.

        • Machtinger E.L.
        • Haberer J.E.
        • Wilson T.C.
        • Weiss D.S.
        Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders.
        AIDS and Behavior. 2012; 16: 2160-2170
        • Machtinger E.L.
        • Wilson T.C.
        • Haberer J.E.
        • Weiss D.S.
        Psychological trauma and PTSD in HIV-positive women: A meta-analysis.
        AIDS and Behavior. 2012; 16: 2091-2100
        • MacMillan H.L.
        • Wathen C.N.
        • Jamieson E.
        • Boyle M.H.
        • Shannon H.S.
        • Ford-Gilboe M.
        • McNutt L.A.
        • et al.
        Screening for intimate partner violence in health care settings: A randomized trial.
        Journal of the American Medical Association. 2009; 302: 493-501
        • Miller E.
        • Decker M.R.
        • McCauley H.L.
        • Tancredi D.J.
        • Levenson R.R.
        • Waldman J.
        • Silverman J.G.
        • et al.
        A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion.
        Contraception. 2011; 83: 274-280
        • Moffitt T.E.
        • The Klaus-Grawe 2012 Think Tank
        Childhood exposure to violence and lifelong health: Clinical intervention science and stress-biology research join forces.
        Development and Psychopathology. 2013; 25: 1619-1634
        • Morrissey J.P.
        • Jackson E.W.
        • Ellis A.R.
        • Amaro H.
        • Brown V.B.
        • Najafits L.M.
        Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders.
        Psychiatric Services. 2005; 56: 1213-1222
        • National Strategy Group to Develop a Model of Trauma-informed Primary Care for Women Living with HIV
        Executive summary: Strategy meeting on trauma-informed primary care for U.S. women living with HIV.
        Positive Women's Network - USA, Oakland, CA2013 (Available:) (Accessed January 28, 2015)
        • Nelson H.D.
        • Bougatsos C.
        • Blazina I.
        Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force recommendation.
        Annals of Internal Medicine. 2012; 156 (W-279, W-280, W-281, W-282): 796-808
        • Ramsay J.
        • Rivas C.
        • Feder G.
        Interventions to reduce violence and promote the physical and psychosocial well-being of women who experience partner violence: A systematic review of controlled evaluations: Final report.
        Barts and the London, Queen Mary's School of Medicine and Dentistry, London2005
        • Sikkema K.J.
        • Hansen N.B.
        • Kochman A.
        • Tarakeshwar N.
        • Neufeld S.
        • Meade C.S.
        • Fox A.M.
        Outcomes from a group intervention for coping with HIV/AIDS and childhood sexual abuse: Reductions in traumatic stress.
        AIDS and Behavior. 2007; 11: 49-60
      9. Substance Abuse and Mental Health Services Administration. (2014a). National registry of evidence-based programs and practices. Available: Accessed March 24, 2014.

        • Substance Abuse and Mental Health Services Administration
        SAMHSA's concept of trauma and guidance for a trauma-informed approach.
        SAMHSA, Rockville, MD2014 (Available:) (Accessed March 1, 2015)
        • Toussaint D.W.
        • VanDeMark N.R.
        • Bornemann A.
        • Graeber C.J.
        Modifications to the Trauma Recovery and Empowerment Model (TREM) for substance-abusing women with histories of violence: Outcomes and lessons learned at a Colorado substance abuse treatment center.
        Journal of Community Psychology. 2007; 35: 879-894
      10. The Sanctuary Model. (n.d.). The Sanctuary Model: An Integrated Theory. Available: Accessed March 31, 2015.

      11. U.S. Department of Veterans Affairs National Center for PTSD. (2015). Available: Accessed March 3, 2015.

      12. U.S. Department of Veterans Affairs National Center for PTSD. (2014). Co-occurring conditions. Available: Accessed January 28, 2015.

        • van der Kolk B.A.
        • Stone L.
        • West J.
        • Rhodes A.
        • Emerson D.
        • Suvak M.
        • Spinazzola J.
        Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial.
        Journal of Clinical Psychiatry. 2014; 75: e559-e565
      13. White House Interagency Federal Working Group on the Intersection of HIV/AIDS, Violence Against Women and Girls, and Gender-Related Health Disparities. (2013). Addressing the intersection of HIV/AIDS, violence against women and girls, & gender-related health disparities. Available:–2013.pdf. Accessed January 16, 2015.

        • Wyatt G.E.
        • Hamilton A.B.
        • Myers H.F.
        • Ullman J.B.
        • Chin D.
        • Sumner L.A.
        • Liu H.
        • et al.
        Violence prevention among HIV-positive women with histories of violence: Healing women in their communities.
        Women's Health Issues. 2011; 21: S255-S260


      Edward L. Machtinger, MD, is a Professor of Medicine and Director of the Women's HIV Program at UCSF. His research focuses on the impact of trauma on women living with HIV and developing and evaluating models of trauma-informed primary care.


      Yvette P. Cuca, PhD, is a Research Specialist and Project Director at the UCSF School of Nursing. Her work focuses on sexual and reproductive health and rights for women living with HIV.


      Naina Khanna, BS, is Executive Director of Positive Women's Network – USA. Her research interests include the sexual rights of women with HIV, and the ways women with HIV negotiate access to power and decision making.


      Carol Dawson Rose, RN, PhD, is Professor of Nursing at the UCSF School of Nursing. Her research focuses on implementing behavioral health interventions in HIV primary care settings.


      Leigh S. Kimberg, MD, is Professor of Medicine at UCSF, and Program Director of the Program in Medical Education for the Urban Underserved. She is Coordinator of Intimate Partner and Family Violence Prevention for the San Francisco Department of Public Health.