Domestic Violence Education for Florida Healthcare Professionals

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By Nancy Evans, BS

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Isolate the risk factors for domestic violence.
• Describe the healthcare implications of domestic violence.
• List the signs and symptoms of domestic violence.
• Discuss appropriate documentation in cases of suspected domestic violence.
• State Florida’s reporting requirements for domestic violence.
• Identify resources available in the community, the state, and nation.

Domestic violence is a major public health problem around the world and in the United States. It is a crime in all fifty states.

Domestic violence refers to physical, verbal, psychological, sexual, or economic abuse (e.g., withholding money, lying about assets) used to exert power or control over someone or to prevent someone from making a free choice. According to the U.S. Department of Justice (2010), “This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.” Rape, incest, and dating violence are all considered to be forms of domestic violence.

According to Florida s.741.28:

Domestic violence means any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury of one family or household member by another family or household member.

Family or household member means spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family or who have resided together in the past as if a family, and persons who are parents of a child in common regardless of whether they have been married. With the exception of persons who have a child in common, the family or household members must be currently residing or have in the past resided together in the same single dwelling unit.

Because the term domestic violence tends to overlook male victims as well as violence between same-sex partners, the Centers for Disease Control and Prevention (CDC) prefers the more specific term intimate partner violence (IPV). Some agencies prefer the term domestic abuse because it makes visible the nonphysical components of an abusive situation; these include psychological or emotional abuse, threatening, and stalking, as well as neglect or financial exploitation, particularly of older people. Family violence is also used to describe abusive domestic situations because any children in the family are affected, either as witnesses of violence and/or as victims themselves.

INCIDENCE AND PREVALENCE

Who Is Affected?

Domestic violence strikes all ages, cultural/ethnic/religious groups, and social classes. Intimate partner violence is one of the most common but least reported crimes, so it impossible to know the actual incidence and prevalence. Feelings of shame, fear, and hopelessness often prevent victims from seeking protection and support. Research shows that at least 4 out of 10 incidents of domestic violence are not reported to the police (Durose et al., 2005). Many abused women do not report IPV to their physicians or to anyone else. However, the statistics available confirm that the problem is pervasive and alarming.

IPV AMONG WOMEN

Victims of IPV are usually women and children. Perpetrators of IPV are generally, though not always, men. According to CDC (2009b), each year, women experience nearly 5 million intimate partner–related physical assaults and rapes. (Men are the victims of nearly 3 million intimate partner–related physical assaults.)

More than three fourths of domestic violence victims are women. A landmark international study of 24,000 women in 10 countries found that 1 in 6 women has experienced domestic violence; yet the problem remains mostly hidden. Women who experience domestic violence have more than double the risk of poor health and physical and mental health problems than women not abused (WHO, 2005). According to Lee Jong-Wook, director-general of the World Health Organization (WHO), “This study shows that women are more at risk from violence at home than in the street.”

In 2005, IPV resulted in more 1,500 deaths, more than three fourths of which were women. On average each day, more than 3 women are murdered by their intimate partners in the United States. According to the Bureau of Justice Statistics (2007), nearly one third of female homicides are committed by intimate partners. Females ages 20 to 24 were at greatest risk of nonfatal IPV. Children were exposed to IPV in nearly 40% of cases involving female victims.

IPV AMONG YOUTH

IPV is disturbingly common among high school students. In the 2007 national Youth Risk Behavior Surveillance, about 10% of students in grades 9 to 12 reported having been hurt physically by a boyfriend or girlfriend during the 12 months preceding the survey. Dating violence was more prevalent among African American students than among white or Hispanic students. In another study, nearly 12% of female students reported ever having been physically forced to have sex against their will (Grunbaum et al., 2004).

According to CDC (2009a), those who harm their dating partners are more depressed and more aggressive than their peers. Other characteristics of abusive dating partners include:

• Poor social skills
• Inability to manage anger and conflict
• Belief that using dating violence is acceptable
• Having more traditional beliefs about gender-related roles
• Witnessing violence at home and/or in the community
• Alcohol use
• Behavioral problems in other areas
• Having a friend involved with dating violence

Physical violence and psychological aggression can extend beyond dating partners and affect same-sex peer relationships. An analysis of students in grades 7, 9, 11, and 12 in a high-risk school district found that girls were significantly more likely than boys to report perpetration of physical violence and psychological aggression within dating relationships than boys were. However, boys were more likely than girls to report physically injuring a date, and also more likely than girls to report physical violence victimization and perpetration within same-sex peer relationships (Swahn et al., 2008).

IPV AMONG ELDERS

Many older Americans, particularly women, experience intimate partner violence or abuse perpetrated by their family or other caretakers. According to the American Psychological Association (2007), each year an estimated 2.1 million older Americans experience physical, psychological, or other forms of abuse, neglect, or exploitation. But these statistics show only a small part of a horrific picture. Experts estimate that there are five unreported cases of abuse and neglect for every one reported.

Eight out of 10 abused elders are women, and those over age 80 are the most frequent victims of abuse. Lack of social support is a major risk factor for abuse. A study of 600 women ages 50 to 64 found that more than 5% experienced some form of abuse by their partners within the two years prior to the study. Women on public assistance reported even higher proportions of IPV as did those who had a recent history of homelessness (Somanti & Shibusawa, 2008). One study found that lifetime prevalence of IPV among older women was more than 26%; more than 18% experienced physical or sexual violence, and more than 20% experienced controlling behavior (Bonomi et al., 2007).

Media reports give the erroneous impression that elder abuse occurs primarily in nursing homes, but research indicates that most abuse and neglect of elders occurs at home. Most of the time, the perpetrators are spouses or family members (Hildreth et al., 2009).

Older women in abusive situations are the least likely to report IPV, primarily due to social and cultural values. A woman brought up in pre-1960s America tends to see her role as obeying her husband without question, believing that “you don’t air your dirty laundry in public.” Admitting that she’s being abused is admitting failure in the relationship. Some studies suggest that when asked, women will tell their physicians or other healthcare provider about abuse. However, most older women who do confide in someone about their abuse usually tell a close friend or family member.

Older women are more likely than younger women to experience violence for a longer time, generally a continuation of behaviors established early in a marriage. For some, however, abuse may begin in a new relationship after the divorce or death of a partner. For others, a decades-long marriage may become abusive for several reasons: failing health or disability of one partner, retirement, sexual changes, dementia, or use of alcohol or other drugs (Wilke & Vinton, 2005).

IPV IN IMMIGRANT AND REFUGEE COMMUNITIES

Although the precise incidence and prevalence of IPV among immigrant and refugee communities is unknown, IPV does exist within these groups. Several factors make it especially difficult for victims (primarily women) to seek or obtain help. The abuser may threaten to use the victim’s immigration status against her, evoking fear of deportation. Language barriers and lack of familiarity with U.S. systems are a further burden. A victim may also fear that reporting violence to the authorities will result in a hostile, insensitive, discriminatory response. In reality, that fear may be justified in some areas of the U.S. where mainstream organizations lack multicultural understanding or reflect prejudicial attitudes toward immigrants and refugees (Family Violence Prevention Fund, 2009).

Patriarchal cultural attitudes and victim-blaming also contribute to IPV in immigrant and refugee communities, just as they do throughout the United States. A study of more than 3,400 women found that the prevalence of IPV was higher among Latina than among non-Latina women (20% vs. 14% for the past 5 years, and 11% vs. 7% for the past year). Latina women also reported more physical symptoms and adverse mental health effects than did non-Latina women (Bonomi et al., 2009).

DOMESTIC VIOLENCE IN FLORIDA

According to the Florida Department of Law Enforcement (FDLE, 2009), the steady increase in Florida domestic violence cases ended in 1998 and continues to decline. Between 1992 and 2008, the rate of domestic violence cases (per 100,000 population) declined nearly 27%.

Although this downward trend is encouraging, domestic violence remains one of Florida’s most serious social problems. In 2008, domestic violence offenses accounted for 89% of violent crimes in Florida. That year, the number of reported cases of domestic violence exceeded 113,000 (FDLE, 2009).

Despite the downward trend in the numbers of domestic violence cases, domestic violence homicide, manslaughter, and stalking are increasing. The initial 6-month data for 2009 showed a disturbing 8.9% increase in domestic violence homicides, a 100% increase in domestic violence manslaughters, and a 38% increase in stalking, which often precedes homicide (FDLE, 2010).

A survey of Florida taxpayers found that most people believe that domestic violence is common. More than half the survey population reported knowing a victim of domestic violence. The vast majority indicated that treatment should be required for people who have physically abused someone. Most Floridians (85.3%) believe that imprisonment is the appropriate punishment for domestic violence incidents involving serious bodily injury (Florida Department of Corrections, 1999).

An overwhelming majority of Florida taxpayers believe that the state needs to spend more on prevention and treatment of domestic violence and on law enforcement related to domestic violence, even if it means an increase in taxes (Florida Department of Corrections, 1999).

Risk Factors

The risk of becoming a victim of IPV is highest among American Indian and Alaskan Native women and men, African American women, Hispanic women, young women, women who are separated or divorced, and women below the poverty line (BJS, 2007). Other risk factors include alcohol and drug use, high-risk sexual behavior, having witnessed or experienced violence as a child, being poorly educated, and unemployment. Women whose male partner is verbally abusive, jealous, or possessive are at high risk for IPV. Couples with disparities in income, education, or job status are also at higher risk for IPV (Crandall et al., 2004).

POVERTY

Poverty damages health and well-being in countless ways; exposure to domestic violence is just one. Women in households with the lowest annual incomes have the highest average annual rates of IPV. Women living in rental housing had three times the rate of IPV of women living in owned housing (BJS, 2007).

When IPV and persistent poverty intersect, they limit coping options. Both poverty and IPV lead to stress, feelings of powerlessness, and social isolation, which combine to produce posttraumatic stress disorder, depression, and other emotional difficulties (Goodman et al., 2009). Such women face risks from the batterer and risks resulting from their poverty. Risks from the batterer include physical injury; threats and loss of security, housing, and income; and potential loss of their children. Risks from poverty include food insecurity, lack of access to health insurance and healthcare, possibly racism, unsafe neighborhoods, and poor schools for their children.

The double jeopardy of poverty and IPV challenges abused women and the healthcare and social service professionals responsible for protecting them. Intervening to stop the violence is only the first step. Issues of income, housing, and healthcare—both mental and physical—must also be addressed.

FAMILY/CAREGIVER STRESS

Families stressed by illness, unemployment, alcohol, and/or drug use are more likely to experience violence. This is particularly true with elder abuse, especially if the older person is frail or mentally impaired, the caregiver is ill-prepared for the task, or needed resources are unavailable. Adult children who abuse their parents frequently suffer from mental and emotional disorders, alcoholism, drug addiction, and/or financial problems that make them dependent on the parents for support.

Violence is a learned behavior and creates a painful legacy in some families. These families respond to tension or conflict with violence because they have not learned any other way to respond.

The National Domestic Violence Hotline (NDVH) answers 21,000 calls each month. Since the economic downturn began in 2008, calls to NDVH have increased significantly, and more than half the calls indicated a change in household financial situation (NDVH, 2009). Three out of four domestic violence shelters reported an increase in women seeking assistance from abuse since September 2008 (Mary Kay, 2009). This trend confirms earlier research showing that domestic violence increases when couples are experiencing financial stress such as unemployment (Benson & Fox, 2002, 2004).

PREGNANCY

Pregnancy may trigger or intensify domestic violence, particularly if the male partner is unemployed or sees the child as a rival for the woman’s time and attention. Violence occurs in up to 8% of pregnancies and is particularly associated with unplanned pregnancy. More than 300,000 women each year experience IPV during their pregnancy (Gazmararian et al., 2000).

Homicide was a leading cause of injury deaths among pregnant and postpartum women in the United States during the 1990s (Chang et al., 2005). Risk factors for pregnancy-related homicide included: age younger than 20 years, African American, and late or no prenatal care. Firearms were the most common method of homicide.

DISABILITY/IMPAIRMENT

People with disabilities, especially women, are at higher risk for IPV, particularly sexual violence, than people without disabilities: 33% and 21%, respectively. In addition, those who have a disability experience abuse for longer periods of time (Barrett et al., 2009). The perpetrators of domestic sexual violence, including sexual abuse, sexual assault, and rape, are most often male caregivers who may be family members. Sixteen percent of violent crimes against females with a disability were committed by an intimate partner (BJS, 2009b).

According to the CDC (2009b), between one fourth and two thirds of adults with cognitive impairments experience sexual violence; rates of sexual violence among women with cognitive disabilities range up to 79%. Reported rates among adolescent boys with disabilities range up to 6%, while reported rates for adolescent girls with disabilities are about 24%.

Having a disability limits a woman’s options for escaping or resolving the abuse. For example, if an abusive partner withholds needed equipment, such as a wheelchair or assistance with dressing or getting out of bed, this prevents access to programs that could help end the abuse (Nosek et al., 2001). Unemployment further disadvantages women with disabilities, decreasing their chances of being able to break the cycle of violence (Smith & Strauser, 2008).

Women living with HIV also can be at increased risk for IPV. According to the National Women’s Health Information Center, many HIV-positive women report emotional, physical, or sexual abuse at some time after their diagnosis.

WHAT DOES INTIMATE PARTNER VIOLENCE LOOK LIKE?

Four Types of IPV

Saltzman and colleagues (2002) identify four types of IPV:

• Physical violence
• Sexual violence
• Threats of physical or sexual violence
• Psychological/emotional violence

They define physical violence as “the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person.“

Sexual violence has three categories: “(1) use of physical force to compel a person to engage in a sexual act against his or her will, even if the act is not completed; (2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and (3) abusive sexual contact.”

Sexual violence can also include reproductive coercion, such as deliberately exposing a partner to sexually transmitted infections (STIs); attempting to impregnate a partner against her will (by damaging condoms or throwing away her birth control pills, also called birth control sabotage); threats or acts of violence if the partner does not comply with the perpetrator’s wishes concerning the decision to terminate or continue a pregnancy; as well as threats or acts of violence if the partner refuses to have sex (Family Violence Prevention Fund, 2008). In a recent study of women ages 16 to 29 years seeking care in family planning clinics, researchers found that more than half of these women reported IPV and 1 in 5 of them reported pregnancy coercion and birth control sabotage. Both IPV and reproductive coercion are associated with unintended pregnancy (Miller et al., 2010).

Threats of physical or sexual violence include the use of “words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm.”

Psychological/emotional violence “involves trauma to the victim caused by acts, threats of acts, or coercive tactics.” Psychological/emotional abuse can include but is not limited to humiliation, controlling what the victim can and cannot do, withholding information, deliberately embarrassing the victim, isolating the victim from family and friends, and denying access to money or other basic resources.

Stalking

Stalking is considered by the federal government, all 50 states, the District of Columbia, and U.S. territories as a type of IPV and a criminal act. Stalking is defined as a course of conduct directed at a specific person that would cause a reasonable person to feel fear (BJS, 2009A).

The Bureau’s Supplemental Victimization Survey (2006) identified seven types of harassing or unwanted behaviors consistent with a course of conduct experienced by stalking victims. The survey classified as stalking victims those who experienced at least one of the following behaviors on at least two separate occasions:

• Making unwanted phone calls
• Sending unsolicited or unwanted letters or e-mails
• Following or spying on the victim
• Showing up at places without a legitimate reason
• Waiting at places for the victim
• Leaving unwanted items, presents, or flowers
• Posting information or spreading rumors about the victim on the Internet, in a public place, or by word of mouth

Although these acts individually may not be criminal, collectively and repetitively they may cause a victim to fear for his or her safety or the safety of a family member.

Stalking often precedes murder or attempted murder of women by their intimate partners (femicide). Researchers reported that three fourths of women murdered by their former partners had been stalked by their partners in the year prior to their murder. Most women were stalked after the relationship had ended. More than half of femicide victims had reported the stalking to police before they were killed by their stalkers (McFarlane et al., 1999).

The National Center for Victims of Crime (2003) defines cyberstalking as “threatening behavior or unwanted advances directed at another using the Internet and other forms of online and computer communications.”

Cyberstalking has become an all-too-common means of harassment, particularly by spurned intimate partners. For example, one Florida woman reported to the Tampa police that a man she had dated for eight weeks called her 600 times in two days after their breakup. In addition, he sent her more than 100 emails in one month (Kalfrin, 2007). As with other forms of IPV, victims often fail to report cyberstalking.

Digital Abuse

The explosion of digital technology—cellular phones, GPS systems, the Internet and social networking sites such as Facebook and YouTube—has made teens the most “connected” generation in history. However, this technology is abused by some, resulting in cyberstalking, cyberbullying, harassment, sexting (sharing naked images of themselves or others), and dating abuse. Collectively, these activities are known as digital abuse, which is pervasive among teens (Associated Press-MTV, 2009).

Half of people ages 14 to 24 reported experiencing digitally abusive behavior, and females were more likely to have been targeted than males. Nearly 1 in 4 young people currently in a dating relationship report that their dating partner checks up with them many times each day either online or by cell phone to see where they are, whom they are with, and what they’re doing. Others report that their dating partners attempt to manipulate and control them by checking the text messages on their phone without permission, demanding their passwords, or demanding that they “unfriend” former dating partners on social networks.

The Cycle of Violence

Research indicates that intimate partner violence (IPV) occurs in a three-phase cycle (Walker, 1984):

1. A period of increasing tension, leading to
2. The battery, followed by
3. A “honeymoon” period of calm and remorse in which the abuser is kind and loving and begs for forgiveness.

When stress and conflict begin to build, the cruel cycle begins again. Over time, the first two phases grow longer and the honeymoon phase diminishes and eventually disappears.

Why Perpetrators Abuse

People outside of abusive relationships often wonder both why a perpetrator abuses and why a victim of abuse remains in such a relationship. Health professionals need to understand the complexity of factors in these relationships to make accurate assessments and offer appropriate assistance. Abusers want power and control, and all their various behaviors are intended to achieve that end.

Although an abuser’s behavior may arise from or be exacerbated by a mental illness, that is not usually the case; however, abusive behaviors may be complicated by substance abuse problems. Health professionals should be alert to any signs of these complicating factors when making assessments.

Why Victims Stay

There are many reasons why victims stay in abusive relationships, and in any given relationship there may be numerous factors that form an interrelated web. These reasons can be divided into three broad categories: situational factors, emotional factors, and personal beliefs.

WHY WOMEN STAY IN ABUSIVE RELATIONSHIPS

Source: WRAP, n.d.
Situational Factors	Economic dependence and inability to support herself and her children Fear of greater physical danger to herself and her children if they try to leave Fear of being hunted down and suffering a worse beating than before Fear of being killed if she leaves, often based on real threats by her partner Fear of emotional damage to the children Fear of losing custody of the children, often based on her partner’s remarks Lack of alternative housing; nowhere else to go Lack of job skills or the inability to get a job Social isolation resulting in lack of support from family and friends Social isolation resulting in lack of information about her alternatives Lack of understanding from family, friends, police, ministers, etc. Negative responses from community, police, courts, social workers, etc. Fear of involvement in the court process, sometimes due to bad prior experiences Fear of the unknown (“Better the devil you know than the devil you don’t”) Fear and ambivalence over making formidable life changes “Acceptable violence,” in which the violence escalates slowly over time and numbs the victim so that she is unable to recognize a pattern of abuse Fear of losing ties to the community, including the children leaving their school, leaving behind friends and neighbors, losing contact with her “old life” Ties to her home and belongings Family pressure (“Mom always told you it wouldn’t work out,” or “You made your bed, now sleep in it”) Fear of her abuser doing something to “get” her (reporting her to welfare, calling her workplace, etc.) Inability to access resources due to language barriers, disability, homophobia, etc. Lack of time needed to plan and prepare to leave
Emotional Factors	Insecurity about being alone or on her own; fear she can’t cope with home and children by herself Loyalty (“He’s sick; if he had a broken leg or cancer,I would stay. This is no different.”) Pity, feeling sorry for him Wanting to help (“If I stay, I can help him get better.”) Fear that he will commit suicide if she leaves, often based on her partner’s remarks Denial (“It’s really not that bad. Other people have it worse.”) Love, particularly when the abuser is quite loving and lovable when he is not being abusive Love, especially when remembering what he used to be like Guilt, believing that their problems are all her fault, often with the agreement of her partner Shame and humiliation in front of the community (“I don’t want anyone else to know.”) Unfounded optimism that the abuser will change Unfounded optimism that things will get better, despite all evidence to the contrary Learned helplessness, as a result of trying every possible method to change things without success, thereby coming to expect failure (also seen with prisoners of war, hostages, those in extreme poverty, etc.) False hope (“He’s starting to do things I’ve been asking for,” such counseling, anger management, etc. Feeling responsible, as though she only needs to meet some set of vague expectations in order to earn the abuser’s approval Insecurity over her potential independence and lack of emotional support Guilt about the failure of the marriage/relationship Demolished self-esteem (“Just like he says, I’m too fat, stupid, ugly, etc.) to leave.”) Simple exhaustion, feeling too tired and worn out from the abuse to leave
Personal Beliefs	Parenting: that the children need two parents (“A crazy father is better than none at all.”) Religious and family: pressure to keep the family together no matter what Duty (“I swore to stay married till death do us part.”) Responsibility: it is up to her to work things out and save the relationship Belief in the American dream of growing up and living happily ever after. Identify: being raised to feel that all women need a partner—even an abusive one—in order to be complete or accepted by society Violence: thinking all partners relate this way (often among women who experienced a violent childhood) Other religious and cultural beliefs

While most victims of domestic violence are women, men are sometimes victims. Like women, men remain in these relationships for a variety of reasons. The most frequent seem to be:

• Protecting their children: afraid to leave their children alone with the abuser, that they will never be allowed to see their children again, that the abuser will turn the children against them
• Assuming blame (guilt-prone): believe that they deserve the abuse treatment or that it is their fault; feel responsible or that they can and should do something to fix things
• Dependency (or fear of independence): feel mental, emotional, or financial dependence on the abuser
  (Oregon Counseling, 2006)

It is important for healthcare professionals to understand the many reasons why victims remain in these relationships in order to provide appropriate treatment, assistance, and referrals. However, it is also important to note that speculating on the reasons with a victim or within their earshot is to turn the focus onto the victim’s behavior when it should always remain on the abuser’s behavior.

HEALTHCARE AND DOMESTIC VIOLENCE

Domestic violence has an enormous impact on the health of those who are affected as well as on the healthcare system.

Health Effects of Intimate Partner Violence

Injuries sustained during episodes of violence are only part of the damage to victims’ health. Physical and psychological abuse are related to other adverse effects, including back pain, pelvic pain, gynecological disorders, gastrointestinal disorders, problem pregnancies, sexually transmitted diseases (STDs), headaches, central nervous system disorders, and heart or circulatory conditions (Coker et al., 2000; Campbell et al., 2002; Heise & Garcia-Moreno, 2002; Plichta, 2004; Tjaden & Thoennes, 2000).

Intimate partner violence is also linked to mental health problems, including depression, anxiety, antisocial behavior, low self-esteem, inability to trust men, fear of intimacy, and posttraumaticstress disorder (Dutton, 2009). Women who have experienced IPV also have an increased risk of substance abuse, suicide, and risky sexual activity (SOGC, 2005).

Intimate partner violence often leads to chronic pain and/or depression. Although chronic pain and depression may have causes other than IPV, either symptom should alert healthcare providers to ask about IPV, especially in older patients (Zink et al., 2005).

EFFECTS OF IPV ON PREGNANT WOMEN

Battering can lead to high blood pressure or edema, vaginal bleeding, kidney or urinary tract infection, miscarriage, preterm labor, low birthweight, or other injury to the developing fetus (Silverman et al., 2006) as well as to posttraumatic stress disorder. The stress of abuse may also cause pregnant women to continue such unhealthy habits as smoking and drug or alcohol use.

Maternal mortality is 3 times as high for abused mothers, and abused African American mothers are 4 times as likely to die as their white counterparts. IPV also increases the risk of fetal death to approximately 16 per 1000 affected pregnancies (Boy & Salihu, 2004). Abused women are also at high risk for postpartum depression, which can interfere with breastfeeding and affect their relationships with their babies and other children as well as with other adults (Kendall-Tackett, 2007).

EFFECTS OF IPV ON CHILDREN

Research indicates that as many as 10 million American children witness IPV within their families each year (Carlson, 2000). Even if they are not physically injured, these children report numerous fears about their mothers, including fear of serious harm to her and to themselves, as well as fear of abandonment. Living with intense anger and unpredictable behaviors creates a chronic, corrosive anxiety state, which researchers call toxic stress. This toxic stress can interfere with normal brain development and compromise long-term physical and mental health (National Scientific Council on the Developing Child, 2005).

Witnessing IPV in childhood can result in such effects as alcoholism, illicit drug use, IV drug use, and depression during adulthood (Dube et al., 2002). Exposure to IPV as a child can also lead to intergenerational transmission of violence, both physical and psychological perpetration and victimization. Researchers write that “childhood exposure to violence is a consistent predictor of involvement in relationships characterized by violence for males and females” (Gover et al., 2008). Child victims of violence, particularly boys, often grow up to become batterers themselves.

In another study, women exposed to IPV as children were three times more likely to report IPV victimization as adults. Men exposed to IPV in childhood were nearly four times more likely to report IPV perpetration as adults (Whitfield et al., 2003). Both men and women were more likely to attempt suicide (Dube et al., 2001).

Screening and Assessment

Women are the most frequent consumers of healthcare services and the most common victims of domestic violence. This puts healthcare providers in the best position to identify victims of domestic violence and make appropriate referrals to protect them against further harm.

Primary care providers whose practice includes women have a critical role in identifying IPV and intervening appropriately. Professional organizations have recommended routine screening of patients and families for domestic violence, including the American Medical Association (2005) and the American Nurses Association (2000).

LACK OF SCREENING

Even though many healthcare providers are alert to signs of potential child abuse, too few screen for IPV among adults. One third of U.S. physicians surveyed said that they don’t record patients’ reports of domestic violence and 90% don’t document whether patients are offered information or other support. One third of physicians surveyed admitted that they did not feel confident about counseling patients who reported IPV (Gerber, 2005). Even though the prevalence of elder abuse was recently reported at more than 11% (Acierno et al., 2010) in people over 60, only 2% of reported elder abuse cases come through physicians.

Another survey of social workers, family practitioners, and obstetrician-gynecologists in Florida found that only 20% of participants always or nearly always routinely screened for domestic violence, and 24% reported that routine screening did not apply to their role (Tower, 2006).

Barriers to routine screening include inadequate educational and experiential preparation, as well as “real world” pressures of daily primary-care practice (Gutmanis et al., 2007). Lack of relevant education on screening also could be a major reason why physicians often fail to screen for IPV/elder abuse (Halphen et al., 2009). Researchers in Michigan reported that “elder abuse education is not a consistent or highly prioritized topic in many primary-care residency programs” (Wagenaar et al, 2009).

Nurses and physicians in all settings where older people receive care need to be aware of the possibility of IPV and elder abuse as well as their legal requirements for reporting the abuse to the appropriate government agencies. Home care workers and pre-hospital care providers (paramedics) also need education on the signs and symptoms of IPV/elder abuse and neglect. In Maryland, one fourth of pre-hospital care providers surveyed defined elder abuse as a social problem, not a medical problem. Likewise, one third of respondents indicated that they would suspect dementia, depression, or other reasons rather than abuse for a report of sexual assault in an elderly patient (Rinker, 2009).

SCREENING TOOLS

Every healthcare facility serving women, children, and older adults needs to screen for potential domestic violence. This screening need not be lengthy. In fact, researchers have developed an effective 2-minute assessment screen for early detection of abuse of women (Brown et al., 1996). The screening can be part of the intake interview or included as part of the written history.

SCREENING TOOL FOR ABUSE OF WOMEN

Question	Circle Best Answer
Source: Centre for Studies in Family Medicine, University of Western Ontario, London, Canada, n.d. Used with permission.
1. In general, how would you describe your relationship?	A lot of tension	Some tension	No tension
2. Do you and your partner work out arguments with…	Great difficulty	Some difficulty	No difficulty
3. Do arguments ever result in you feeling put down or bad about yourself?	Often	Sometimes	Never
4. Do arguments ever result in hitting, kicking, or pushing?	Often	Sometimes	Never
5. Do you ever feel frightened by what your partner says or does?	Often	Sometimes	Never
6. Has your partner ever abused you physically?	Often	Sometimes	Never
7. Has your partner ever abused you emotionally?	Often	Sometimes	Never
8. Has your partner ever abused you sexually?	Often	Sometimes	Never

The University of Maine Center on Aging (2007) has developed a brief screening protocol for screening older patients for domestic abuse and violence. The center recommends that all patients 60 years old and older should be routinely screened at least once a year for elder mistreatment. The protocol consists of a brief introduction followed by 6 questions:

SCREENING TOOL FOR ELDER ABUSE

Question	Circle One
Source: Adapted by the University of Maine Center on Aging, 2007. Used with permission.
1. Has anyone close to you called you names or put you down recently?	Yes	No
2. Are you afraid of anyone in your life?	Yes	No
3. Are you able to use the telephone any time you want to?	Yes	No
4. Has anyone forced you to do things you didn’t want to do?	Yes	No
5. Has anyone taken things or money that belong to you without your OK?	Yes	No
6. Has anyone close to you tried to hurt you or harm you recently?	Yes	No

Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of the patient’s family, caregiver, or the person who brings the patient to the appointment.

LOOKING FOR SIGNS AND SYMPTOMS RELATED TO IPV

Healthcare providers should be alert for signs and symptoms that may be related to IPV. Delay in seeking care, missed appointments, and vague or inconsistent explanation of injuries or nonspecific somatic complaints should be noted. Depression, chronic pain, and social isolation are common, as are substance abuse and use of alcohol or drugs. Be especially attuned to signs of abuse in pregnant clients, because abuse often escalates during pregnancy.

During the appointment, be aware of lack of eye contact and/or a husband or boyfriend who is reluctant to leave the woman alone with the healthcare provider. Victims of abuse may appear fearful, anxious, withdrawn, angry, nonresponsive, or afraid to talk openly. Suicide attempts may be directly related to IPV.

During the physical examination, look for injuries on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals. Note any bruises, burns, or wound patterns that resemble teeth marks, hand prints, belts, or cigarette tips. Note any pain or tenderness from touching. Be alert for puncture wounds, fractures and dislocations, scars on the vulva or rectum, or any unexplained vaginal or anal bleeding, particularly in older people. Be aware that the woman may wear a glove or sock to conceal a scalded hand or foot.

Following an established procedure for examination will ensure that no critical information is overlooked:

• Have patient undress and don an exam gown that will allow all areas of the body to be examined
• Check the pattern of injuries
• Document physical assessment finds quantitatively and in detail
• Record visual evidence via still or video camera. Be sure to include full-body views as well as individual views of each injury with an object provided for size reference (e.g., ruler, coin)
• Conduct mental status exam
• Use open, nonjudgmental questions that neither imply blame nor ask why
• Recognize potential evidence; collect, preserve, and maintain chain of custody
• Explain all therapeutic protocols, including evidence collection, to patient
  (KBN, 1997)

Women who show signs of physical abuse should also be screened for STIs, including chlamydia, human papilloma virus, gonorrhea, and syphilis. One study found that approximately 64% of rural women with an STD are involved in an abusive physical and sexual relationship (Clifford, 2003).

DOCUMENTING SUSPECTED DOMESTIC VIOLENCE

Accurate, thorough documentation of the patient’s injuries is essential in cases of suspected abuse because it can serve as objective, third-party evidence useful in legal proceedings. For example, medical records can help victims to obtain a restraining order or to qualify for public housing, welfare, health and life insurance, and immigration relief.

To be admissible in a court of law, medical documentation should include the following (Isaac & Enos, 2001):

• Photographs of the injuries, taken during the initial examination
• Body maps, which document the extent and location of the injuries
• Description of the patient’s demeanor (crying, angry, agitated, upset), including a record of the patient’s comments about how the injuries occurred. The patient’s own words should be set off in quotation marks or identified by such phrases as “the patient states” or “the patient reports.”
• Any description in which the patient identifies the abuser, such as "my boyfriend kicked me."
• The time of day when the patient is examined and, if possible, how much elapsed time since the injuries occurred. For example, “patient says that last night her husband punched her.”
• Legible handwriting. Too often, doctors’ or nurses’ poor handwriting on medical records makes the documentation inadmissible as evidence.

Treatment Plan

When assessment and examination are complete, review any therapeutic protocols with the client and provide a supportive and encouraging environment in which the client can seek help and get support. Be prepared to:

• Provide appropriate diagnostic and therapeutic interventions in collaboration with other providers, if needed
• Provide verbal and written information about domestic violence and legal options
• Provide a listing of relevant community resources
• Make any necessary referrals
• Initiate mandatory reporting procedures when required

(A list of resources appears at the end of this course.)

Healthcare professionals should also use the following questions to evaluate immediate safety issues:

• Where is the abuser now?
• Does the abuser know where the client is now?
• Has the abuser threatened to use weapons?
• Are weapons available to the abuser?
• Is the abuser intoxicated?
• Does the abuser have a criminal record?
• Are there children? Are they safe now?
• Are they being abused?
• Is the abuser verbally threatening the patient?
• Is the abuser frightening relatives and friends?

Be sure you understand and can implement your facility’s established safety protocols.

LEGAL REPORTING REQUIREMENTS IN FLORIDA

The person reporting abuse should be prepared to describe:

• Victim name, address or location, approximate age, race, and sex
• Signs or indications of harm or injury, including a physical description if possible
• Relationship of the alleged perpetrator to the victim, if possible. If the relationship is unknown, a report will still be taken if other reporting criteria are met.

Vulnerable Adult Abuse

Florida law requires healthcare providers and others to report suspected abuse of vulnerable adults to the Florida Abuse Hotline. Abuse means any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult’s physical, mental, or emotional health. Abuse includes acts and omissions (415.102(1), F.S.). All reports are confidential, including the name of the reporter. A list of the occupations required to report suspected abuse of vulnerable adults is provided in the box below.

In 2006, the Adult Protective Services statute was amended to enable the Department of Children and Families (DCF) to petition the court for an order authorizing the provision of protective services if a vulnerable adult in need of protective services is being abused, neglected, or exploited but lacks the capacity to consent to the provision of protective services (415.105(1), F.S.). In addition, the statute now enables the Agency for Persons with Disabilities (APD) to gain access to information in the central abuse hotline data (415.107, F.S.).

Intimate Partner Abuse

Florida statute 790.24 requires healthcare providers to report gunshot or life-threatening wounds or injuries. Obviously, this does not cover the majority of injuries sustained in IPV. However, reporting suspected domestic violence without the informed consent of the victim is unethical and may cause the abuser to retaliate.

When it is appropriate to report domestic violence, call 1-800-500-1119.

Elder Abuse

Florida law requires that all health professionals, including employees of long-term care facilities, report known or suspected cases of elder abuse.

If the abuse was perpetrated by the spouse/partner or other person known to the victim, it constitutes domestic violence. The National Center on Elder Abuse (2006) encourages health professionals not to try to answer, “Is this domestic violence?” or “Is this elder abuse?” Instead, efforts should be made to maximize both the domestic violence and aging networks services by partnering to meet the unique needs of older victims.

DOMESTIC VIOLENCE RESOURCES IN FLORIDA

The Domestic Violence Program regulates, certifies, and monitors domestic violence centers across the state of Florida. As of 2010, there are 42 certified domestic violence centers that provide crisis intervention and support services to adult victims of domestic violence and their children free of charge, 24 hours a day, 7 days a week.

Most communities also have child protective services and adult protective services agencies to which known or suspected cases of abuse should be reported. (A list of additional resources is provided below.)

Florida law has established batterers intervention programs for perpetrators of domestic violence. Attendance at a batterers intervention program is usually imposed by the court as a condition of probation. According to the Florida Department of Law Enforcement (FDLE, 2010), 75% of those who perpetrate domestic violence are male, and therefore its efforts at certification of and setting standards for these programs has focused on programs designed for men who commit acts of domestic violence.

CONCLUSION

Our society is dealing with what has been called an epidemic level of violence in daily life. Healthcare professionals can make a critical difference in the progress toward ending this costly, destructive epidemic and halting the transmission of violence from generation to generation. By being alert to the possibility of domestic abuse in patients of every age, race, and socioeconomic group, the victims of abuse can be identified, protected, and assisted in resolving their situation.