Translational Research Begins to Explain Chronic Health Problems Associated with Intimate Partner Violence

Last fall, Janice Humphreys, RN, NP, PhD, a family health nurse, and an interdisciplinary group of UCSF colleagues uncovered striking, new information about the long-term health and aging effects of intimate partner violence (IPV).

Building on the work of Nobel Prize-winning biologist Elizabeth Blackburn, PhD, and psychologist Elissa Epel, PhD, the team found clear indications that exposure to IPV, particularly prolonged exposure, hastens biological processes that lead to illness and premature aging.

“For the first time, we showed that there is lasting damage not just to these women’s minds and bodies, but to their cells,” says Humphreys, associate professor in the Department of Family Health Care Nursing in the UCSF School of Nursing. The evidence came in the form of shortened telomeres, critical ends of DNA strands that were central to Blackburn’s Nobel Prize-winning work. Six years earlier, Blackburn and Epel had published a landmark study showing that women who experience chronic stress from caring for their chronically ill and disabled children also have shorter telomeres.

A grant from UCSF’s Clinical and Translational Science Institute (CTSI) supported the IPV study by fostering a collaboration among Humphreys; Blackburn; Epel; Kathryn Lee, RN, PhD, FAAN, associate dean of research in the UCSF School of Nursing; and biochemist Jue Lin, PhD, a postdoctoral fellow in the Department of Biochemistry and Biophysics.

The findings give Humphreys a powerful, new tool in her 30-year fight against the devastating health effects of IPV. She can now draw on her deep knowledge of health care systems to redouble her argument that providers must universally screen for IPV and treat not just the psychological effects, but also the lasting physical effects.

Raising Awareness of Domestic Violence

Thirty years ago, Humphreys knew nothing about IPV or telomeres. She was teaching in the nursing program at Wayne State University when, to maintain her nurse practitioner credential, she volunteered to work in a Detroit-area battered women’s shelter.

“The literature back then said that abused women brought violence on themselves, but that wasn’t what I saw,” says Humphreys. “The women I met seemed to be doing the best they could to deal with the violence, and I decided to try to make a difference by understanding their lives and telling their stories.”

Since then, through her research and advocacy work, Humphreys has tirelessly raised awareness about the prevalence of IPV, its health effects and the role health care providers can play in countering those effects. Given that some studies estimate that as much as 14 percent of women in the United States suffered IPV in the past year, Humphreys’ work has already made an important contribution to the nation’s health.

Among Humphreys’ many contributions is research confirming that those subjected to IPV often do suffer from chronic psychological and physical illness. The mental health concerns tend to focus on conditions such as depression and post-traumatic stress disorder; the physical effects often include severe headaches and lower back and lower extremity pain.

“Women who’ve experienced IPV report chronic physical pain at rates that are comparable to women with osteoarthritis and metastatic cancer,” says Humphreys.

Pregnant women – and the children they carry – are particularly vulnerable to the physical effects. “Studies show that IPV is more common in pregnancy than placenta previa, gestational diabetes, or pregnancy-induced hypertension . . . and has been linked with poor maternal weight gain and anemia, bleeding, placental abruption, uterine rupture, chorioamnionitis, vaginal infections, and kidney infection,” writes Humphreys in a recent paper. “Women reporting IPV had 1.4 times greater odds of [having] a low birth weight infant than nonabused women.”

And yet, even though leading health care organizations have periodically recommended universal screening, “studies show that only about 25 to 30 percent of providers ask anything at all about IPV,” says Humphreys.

Providers often cite lack of time, support resources, education and training; fear of offending the patient; inability to fix the problem; the patient not disclosing; and frustration with lack of change in the patient’s situation or the patient’s unresponsiveness to advice. Those providers who do ask tend to focus only on the psychological trauma, but fail to acknowledge the physical complaints.

“Yet we know that psychological trauma has profound effects on physical health and that we need to address both pathways in our interventions; that’s been nursing’s perspective for decades,” says Jacquelyn Campbell of the Johns Hopkins University School of Nursing, Humphreys’ co-author of the text Family Violence and Nursing Practice.

Humphreys’ latest work may be the proof that other disciplines need to act effectively on that concept.

Study Finds Shorter Telemeres in Abused Women

The idea for her study germinated when Humphreys saw a call for proposals from the UCSF CTSI.

“I spoke with Kathy Lee, who thought that if we could find a biomarker for the health problems that women who’ve experienced IPV describe, we could take this to the next level,” says Humphreys. Lee suggested that Humphreys meet with Epel, who then brought in Blackburn and Lin.

The group successfully applied for a CTSI grant that funded an exploratory study of 112 women ages 18 and older, 66 of whom had experienced IPV and 46 of whom had not. Researchers used a series of questionnaires and interviews to understand and categorize the experiences of these women, as well as to sort out some of the variables. The researchers also measured the women’s height and weight, and took a blood sample from which they could analyze telomere length.

The formerly abused women reported an average length of time in the abusive relationship of 4.8 years, with the average time since the last IPV episode of almost five years. All of the women reported experiencing psychological aggression, and 80 percent also reported severe physical assaults, 58 percent had severe physical injuries and 50 percent reported severe sexual coercion at the hands of their abusers.

What’s the bottom line? “We found that the abused women had shortened telomeres when compared with those who had not been abused – and that length of time in the abusive relationship and having children were the best predictors of telomere shortening,” says Humphreys. “Length of time was associated with telomeres five to 10 chronological years shorter.”

Another – and unexpected – finding was that women with a history of abuse had a higher body mass index (BMI) and shorter telomeres than those who had not been abused. “Given the concern about obesity, the relationship between exposure to abuse, shorter telomeres and elevated BMI needs further study,” says Humphreys.

In short, the study adds to a growing body of literature that finds exposure to life stresses endangers not just the mind, but also the body. “It makes an important biological health statement about IPV,” says Epel. “There’s actual damage at the molecular level, which brings attention and validity to the medical problems these women suffer from.”

“Until now, no one has been able to figure out how someone can have all these problems years after the trauma or stress occurred,” says Humphreys. And as noted above, without that explanation, providers have seemed reluctant to screen for or treat the physical symptoms.

Arresting the Damage of Stress

Now, however, with the association between psychological stress and cellular damage becoming increasingly clear, a doorway may have opened to potential interventions that might at least arrest the damage that stress has inflicted on these women’s bodies.

“It’s speculative at this point, but there are indications, for example, that women who engage in regular forms of vigorous exercise can buffer the effects of stress on cells,” says Humphreys. Or providers might offer these women pain management techniques that combine medication and behavioral therapies.

“These kinds of things could happen right away in primary care,” says Humphreys.

With that in mind, Humphreys has already submitted a proposal with Christine Miaskowski, associate dean in the School of Nursing, to examine chronic pain in formerly abused women over time. They will look at a variety of different measures, using both interviews and detailed physical examinations every three months. “We want to disentangle depression, PTSD, lifetime trauma exposure, physical functioning and chronic pain because we have reason to believe that what we’ll find is there are different trajectories that merit different treatments,” says Humphreys.

“Isn’t it exciting?” asks Campbell. “We’ve known for a long time about the profound physical and mental health effects of trauma, but we haven’t known the mechanism. This work hopefully leads to interventions that can counteract the effects, and it points to the importance of doing collaborative research.”

Epel agrees. “Janice has broken disciplinary barriers by marrying her qualitative methods [that have exposed the devastating health symptoms associated with IPV] with measures of molecular, stress-induced damage,” she says. “That’s an important start, and there’s potential to go even deeper by identifying the specific experiential factors that appear to lead to cellular damage, by explaining the great variance in damage within the group of women exposed to IPV. What types of life circumstances and coping responses might be more protective versus damaging?”

“Working with people who are on the leading edge is a wonderful, unique opportunity,” says Humphreys. “It might have been easier to stay in my world, but for me, it is all about a deep commitment to these women and their children. And it led to a wonderful partnership where each of us had the opportunity to move along our science – and reduce human suffering.”

Editor's note: This story first appeared in the UCSF School of Nursing's Science of Caring magazine, Spring 2011.

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