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COURSE OBJECTIVE: The purpose of this course is to describe the scope and dynamics of domestic violence, risk factors, signs and symptoms, interventions, and resources.
Upon completion of this course, you will be able to:
Domestic violence is a major public health problem around the world and in the United States. It is a crime in all fifty states. In addition to laws specifically related to domestic violence, abusive partners may also be charged with other crimes, such as:
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.
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.
We have to be very careful when citing statistical reports that we don’t create the perception that anyone actually has a handle on the rate of domestic violence in America. The truth is, domestic violence is rampant and diverse, and it’s still something no one wants to talk about.
—SHERYL CATES, Executive Director, National Domestic Violence Hotline
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.
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 quarters 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 quarters of which were women. On average each day, more than three 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 is disturbingly common among high school students. In the 2007 national Youth Risk Behavior Surveillance, about 10% of students in grades nine to twelve 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:
Physical violence and psychological aggression can extend beyond dating partners and affect same-sex peer relationships. An analysis of students in grades seven, nine, eleven, and twelve 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).
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).
Domestic violence also occurs in same-sex couples. The similarities between homosexual IPV and heterosexual IPV appear to be greater than the differences. Conflict occurs and escalates over value differences, financial stress, socioeconomic and educational backgrounds, and racial or ethnic differences. Gay men are more likely to report abuse by same gender partners than heterosexual men are to report victimization by female partners. Women are more likely to experience abuse from males than from lesbian partners (Kulkin et al., 2007).
Same-sex partners also have unique issues such as disclosure of their relationship in communities where homosexuality is stigmatized. If partners do not agree about disclosure of the relationship, the abuser can threaten to “out” the partner, a common type of emotional or psychological abuse.
Among gay male couples, sexual coercion as part of the cycle of domestic violence represents a serious threat for HIV infection. In a study of 302 gay males in Puerto Rico, 47% reported experiences of domestic violence and 27% acknowledged experiencing sexual violence. Researchers found a positive correlation between being anally penetrated without a condom, the need to please the partner, and being HIV positive (Toro-Alfonso & Rodriguez-Madera, 2002).
Although the precise incidence and prevalence of IPV among immigrant and minority 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 five 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).
Researchers call IPV “a serious epidemic” among Asian immigrant communities. Traditional Asian cultures tend to minimize or ignore IVP because it is often considered an acceptable, private family matter. Gender norms in many Asian communities promote male dominance and female submission. Asian women in the United States are less likely to report sexual and physical assault committed by intimates than are women from other racial and ethnic groups. They also are much less likely to seek treatment services and law enforcement protection (Lee & Hadeed, 2009).
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 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.
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 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.
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 quarter 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.
Rural living may present additional problems for women who are victims of domestic violence, as well as for rural healthcare providers who may come in contact with them or be called upon for assistance.
Poverty is more common among rural communities than among urban communities. The increased prevalence of poverty is associated with unemployment, substandard housing, inadequate education, and intensified family stress and conflict. These factors increase the likelihood of abuse and a lack of awareness and information about services and options.
As noted above, isolation (emotional, physical, and economic) may be a factor in some victims staying in abusive relationships, and the geographical circumstances of rural living often make isolation an even more critical factor. Among other things, an abuser may limit a victim’s access to family vehicles or prevent her from obtaining a driver’s license; ridicule her in front of others or accuse her of flirting, thus making her even less likely to invite others to the home or go out herself; or even remove the telephone when leaving the house so she has no means to communicate with others.
These abuser behaviors, in conjunction with factors common to rural living, can make it extremely difficult for abused women to escape. Factors include:
Rural healthcare providers not only need to be able to identify domestic violence victims but also to be prepared to offer assistance that addresses the particular needs and problems of rural women. Safety plans or escape options for rural women need to be adjusted to meet the specific realities of their situations.
Saltzman and colleagues (2002) identify four types of IPV:
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.
Researchers report that psychological/emotional (nonphysical) violence may be more difficult to endure and have more lasting effects than physical violence, particularly in middle-aged and older women. This kind of abuse appears to be more effective in controlling the victim’s behavior than physical violence because it erodes self-esteem and increases uncertainty, hopelessness, and fear. As one woman said, “The persons who come to fear, and then having fear, in order not to stimulate any more violence, they keep quiet, start to tolerate, then the abuser abuses more” (Seff et al., 2008).
The “invisibility” of nonphysical abuse serves as a barrier to reporting the abuse. Victims fear that law enforcement officers would not recognize psychological or emotional violence as a crime. According to one woman, “[The police] want to see the bruises and the black eye and the teeth knocked out.” And another said, “You have no proof of it. You have nothing to show, and you can’t have them arrested” (Seff et al., 2008).
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:
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 quarters 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.
RESPONDING TO CYBERSTALKING
Even though cyberstalking does not involve physical contact with the perpetrator, it can constitute emotional and psychological abuse. NCVC recommends that victims send the stalker one clear written warning stating that the contact is unwanted and demanding a cessation of sending any communications. If the harassment continues, victims should file a complaint with the perpetrator’s Internet service provider (ISP) as well as with their own ISP. Victims should keep copies of all written communications and a log of phone calls. Filing a report with local law enforcement requesting a protective injunction puts the crime on record in the event that legal prosecution becomes necessary.
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.
Research indicates that intimate partner violence (IPV) occurs in a three-phase cycle (Walker, 1984):
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.
People outside of abusive relationships often wonder both why a perpetrator abuses and why a victim of abuse remains in such a relationship. Typically, abusers want power and control, and all their various behaviors are intended to achieve that end.
A model developed by the Domestic Abuse Intervention Project (DAIP, 1984) in Duluth, Minnesota, known as the “Power and Control Wheel,” depicts the most common abusive behaviors or tactics experienced by battered women. It is characterized by the pattern of actions that an individual uses to intentionally control or dominate his intimate partner. These actions fall under eight primary categories:
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.
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.
|Source: WRAP, n.d.|
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:
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.
Domestic violence has an enormous impact on the health of those who are affected as well as on the healthcare system.
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 posttraumatic stress 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).
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 three times as high for abused mothers, and abused African American mothers are four 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).
Research indicates that as many as 10 million American children witness IPV within their families each year (Carlson, 2000). A survey of more than 4,500 children ages 1 to 17 found that nearly 10% had witnessed family assault during the previous year and more than 20% over their lifetime. Among those 14 to 17 years old, more than one third had witnessed an assault between their parents (Finkelhor et al., 2009).
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).
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).
An effective response to domestic violence by nurses and other healthcare professionals depends on three elements—recognition, intervention, and prevention.
Healthcare agencies should have protocols for handling situations in which abuse has been positively identified or the client is requesting specific immediate assistance. Your facility should have protocols that address: interviewing, physical assessment, safety assessment, treatment plan(s), referrals to resources of all types, and a thorough understanding of reporting requirements and methods. These may be best addressed in conjunction with other local agencies, including law enforcement, medical, mental health, and community services.
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 quarter 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).
Every healthcare facility serving women, children, and older adults needs to screen for potential domestic violence. This screening need not be lengthy. 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.
|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 six questions:
|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.
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:
Women who show signs of physical abuse should also be screened for STDs, 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).
Clients suffering from abuse may have complaints or injuries that include arthritis, irritable bowel syndrome, stomach ulcers, chronic pain, migraines, and eating disorders. Other closely associated complaints include insomnia, depression, posttraumatic stress disorder, panic disorder, and substance abuse.
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):
Health professionals should avoid any phrases—such as “patient claims” or “patient alleges”—that cast doubt on the patient’s reliability. Also avoid legal terms such as “alleged perpetrator” or “assailant.” Do not use conclusive terms such as “assault and battery” or “domestic violence” in documenting a case; let the factual information in the record speak for itself.
All healthcare professionals should keep themselves informed of mandatory reporting requirement laws in their jurisdiction, as well as the current status of related statutes. Establish good communication with local law enforcement and judicial offices in order to stay abreast of any changes.
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:
It is also critical to understand and implement your facility’s established safety protocols.
Begin by believing any woman who admits being abused. She has shown trust and courage to disclose the facts. Skillful, nonjudgmental interviewing can help build trust and establish a therapeutic relationship. Holtz and Furniss (1993) developed the following guidelines for care of the abused woman:
|A||Assure the woman she is not alone. Isolation enforced by her abusive partner prevents her from understanding that others are in a similar situation and that healthcare providers can help.|
|B||Express the belief that violence against the woman is unacceptable in any situation and that it is not her fault.|
|C||Ensure confidentiality. She may fear (justifiably) that the abuser will retaliate.|
|D||Document the case thoroughly (see above).|
|E||Educate the woman about the cycle of violence, the likelihood of repeated violence, and her options for ending the abuse.|
|S||Safety. Help the woman formulate a plan of action for either leaving or remaining in the relationship, which some women do for a variety of reasons. Provide information about available resources, such as hotline and shelter numbers. Suggest that a quick getaway bag packed with personal items be hidden or left with a neighbor. If possible, the woman should have an extra set of car keys, house keys, money, and any legal documents needed for identification.|
Healthcare agencies should maintain lists of local resources, including shelters and legal assistance. Be aware of the need to ask a victim if coming across such information is likely to upset the abuser. If at all possible, have available a concealable resource list for victims who need it.
Women with children should take them along to prevent their being abused or held hostage by the abuser. One woman in an abusive relationship had her children go to bed with their shoes on so they could escape at a moment’s notice if their alcoholic father became violent. She trained them to run to the neighbors and ask them to call the police. Children whose mothers are being abused need help in protecting themselves. Depending on their age, children can:
A safety plan is something that an abuse victim can begin working on at any time. Children, when appropriate, should also be helped to establish their own safety plans. Healthcare providers can provide forms that a victim can use to begin preparing both physically and psychologically to escape her abusive situation while protecting herself and her children. Nurses and other healthcare professionals should keep such forms and/or information about accessing and completing them available with other resources for domestic abuse victims.
Healthcare professionals can use the following questions to evaluate immediate safety issues:
Without any sort of intervention, abuse tends to escalate. While not all abusers kill and there are no perfect predictors of time and place, research has revealed some patterns. The time of separation—when an abuse victim leaves her abuser and just afterward—presents the greatest threat to the abuser’s ability to maintain power and control.
A number of other factors have been identified as contributing to increased threat of lethality in an abusive situation (KBN, 1997; Institute of Public Law, 2007):
Prevention of domestic violence and early identification and treatment of victims would likely benefit all healthcare systems in the long run and would eliminate much pain and suffering for survivors of IPV.
Prevention is something everyone can participate in. Empowerment should be the guiding force behind victim advocacy and is something all healthcare professionals can promote. Remember to always:
Communities also benefit from advocacy activities. Healthcare providers may be able to do one or more of the following:
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.
Domestic Abuse Helpline for Men and Women
National Domestic Violence Hotline
TTY number: 800-787-3224
National Resource Center on Domestic Violence
Rape, Abuse, and Incest National Network (RAINN)
Spouse Abuse Shelter Hotline
Battered Women’s Justice Project
Break the Cycle (Teen dating violence)
Centers for Disease Control and Prevention
Choose Respect (CDC-sponsored to end dating violence)
Dating Matters (60-minute interactive training on teen dating violence)
Elder Justice Coalition
Family Violence Prevention Fund
Healthy People 2010
Love Is Not Abuse
National Center on Elder Abuse
National Latino Alliance for the Elimination of Domestic Violence
National Women’s Health Information Center
Violence Against Women Network
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