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This course fulfills the Kentucky requirement of 3 hours of continuing education in domestic violence for nurses.
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to educate Kentucky nurses on the dynamics of domestic violence, effects of domestic violence on adults and child victims, legal remedies for protection, lethality and risk issues, model protocols for addressing domestic violence, available community resources and victim services, and reporting requirements.
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 50 states. Other crimes that may be related to domestic violence include:
Domestic violence (DV) 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.
Domestic violence in Kentucky is defined as an assault against a family member by a family member. Kentucky law defines family member as a current or former spouse, a parent, a grandparent, a child, or a stepchild. It also defines any person living in the same household with a child as a family member if the victim is a child. The law includes persons who have a child or children together, even if unmarried. The unmarried couple’s children are included in this definition as are persons who currently live or once resided together with the alleged victim (KRS 403.720). In addition, the law protects vulnerable adults (age 18 and older) who have mental or physical dysfunction. Many victims of elder abuse also fall within the Kentucky domestic violence laws when the victim and the abuser are related (KRS 209).
This course generally uses the term domestic violence. The Centers for Disease Control and Prevention (CDC) often use the more specific term intimate partner violence (IPV). Other 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 adult family members. Family violence is also used to describe abusive domestic situations because any children in the family may be affected, either as witnesses of violence and/or as victims themselves.
“If the numbers we see in domestic violence were applied to terrorism or gang violence, the entire country would be up in arms, and it would be the lead story on the news every night.”
—Rep. Mark Green (Colorado DHS, 2010)
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 is impossible to know the actual incidence and prevalence. Feelings of shame, fear, and hopelessness often prevent victims from seeking protection and support. Many abused women do not report domestic violence to their physicians or to anyone else. However, the statistics available confirm that the problem is pervasive and alarming.
Domestic violence is an ongoing and critical problem in Kentucky. In fiscal year 2012, the Department for Community-Based Services (DCBS) investigated 19,337 allegations of domestic violence. DCBS also investigated 14,887 allegations of adult abuse, spouse abuse, self neglect, caretaker neglect, and exploitation, 56.5% of which were due to domestic violence (KSP, 2012).
According to the statistics compiled by the Kentucky State Police (KSP) for its annual report Crime in Kentucky 2012, people seeking domestic violence protective orders filed 26,156 petitions. Likewise, the Kentucky Domestic Violence Association received 25,302 domestic violence–related calls and 46,441 calls asking for information and/or referrals (KSP, 2012).
The economic impact that accompanies the personal and emotional impact is clear when we consider that 75% of battered women use work time to deal with the violence in their lives: 64% are late to work, 50% miss at least three days of work per month, and 20% lose their jobs as a result of the violence (KDVA, 2006).
Victims of domestic violence are usually women and children. Perpetrators of domestic violence are generally, though not always, men. According to the CDC (2012), more than 12 million women and men are victims of intimate partner violence over the course of a year. In 2007, IPV resulted in 2,340 deaths and accounted for 14% of all homicides. Of these deaths, 70% were females and 30% were males. Many victims do not report IPV to police, friends, health professionals, or family, so these statistics underestimate the problem.
Teen dating violence is another form of IPV that is disturbingly common among high school students. The nature of dating violence can be physical, emotional, or sexual. Dating violence can also include stalking and can take place in person or electronically. Approximately 9% of high school students reported being hit, slapped, or physically hurt deliberately by a boyfriend or girlfriend (CDC, 2012).
Those who harm their dating partners are more likely to be depressed and more aggressive than their peers. Other characteristics of abusive dating partners include:
A history of teen dating violence can be a risk factor for IPV in adult relationships. Among adult victims of IPV, 22.4% of women and 15% of men have a history of some sort of partner violence between the ages of 11 and 17 (Black, 2011).
Abuse of older adults may be missed by professionals who work with these patients because of a lack of training in detecting abuse. Abuse may go unreported by the victims themselves because they may be unable to physically or cognitively seek help, they do not want to get the abuser in trouble, or they fear retaliation. It is estimated that 90% of elder abuse occurs at the hands of family members and that females are abused at a higher rate than males (NCEA, 2012).
Research indicates that dementia is an important risk factor for elder abuse. One study revealed that close to 50% of people with dementia experience some kind of abuse (Cooper et al., 2009). Another study found that 47% of participants with dementia had been mistreated by their caregivers (Wiglesworth et al., 2010). Approximately 5.1 million Americans over the age of 65 have some kind of dementia, and most states are expected to see an increase in Alzheimer’s disease prevalence by 2025.
Domestic violence is a crime without cultural boundaries. It affects people from all walks of life and does not discriminate against race, religion, or economic class. However, the desire or ability to report the crime and access services may be affected by the person’s culture. Therefore, it is essential for health professionals to consider cultural differences when working with immigrant communities in order to provide appropriate and sensitive services (NIJC, 2013).
Some cultures believe that the family is the only appropriate forum for dealing with domestic violence, and outside interference is not encouraged or accepted. Other ethnicities may even resist acknowledging that domestic violence exists as a problem. It can be challenging to assist victims who do not understand that help is available. Language barriers and lack of knowledge of legal rights or resources can also be an obstacle to seeking help.
The predominant immigrant communities in Kentucky are Asian and Hispanic, with Latinos and Asians making up 4.1% of the population according to a 2013 report by the American Immigration Council. A recent study demonstrated that the Asian population nationwide is less likely to access professional services and tends to use informal means of support such as family and friends. Asian victims seem to utilize formal help less than victims of other racial groups (Cho, 2012).
Hispanics now comprise 16% of the national population and are the largest ethnic minority in the United States. Studies show that although IPV occurs at a similar rate in this population as it does in other ethnic groups, these victims are much less likely to report the abuse or seek help. Possible contributing factors are that the victims may not trust the police, fear deportation, feel shame or guilt, or have a history of child victimization. In addition, the victims may not understand what type of help is available or how to access services.
The U visa is a nonimmigrant visa that was created in 2000 with the passage of the Victims of Trafficking and Violence Protection Act (including the Battered Immigrant Women’s Protection Act). It is a unique visa for victims of crimes who have suffered substantial mental or physical abuse and are willing to assist law enforcement in the investigation or prosecution of the criminal case. It was developed with the intent to strengthen the ability of law enforcement to investigate and prosecute certain types of cases.
Victims who are granted a U visa are given temporary legal status and work eligibility in the United States for up to four years. This program helps law enforcement agencies serve many victims of crimes who would otherwise not be served.
Source: U.S. DHS, 2014.
Persons who identify as lesbian, gay, bisexual, transgender, queer/questioning, or intersex (LGBTQI) experience domestic violence at the same rate as the general population but do not often access services or report to the police. There are many reasons that they do not seek help:
Law enforcement authorities may not recognize same sex individuals as intimate partners and may have a difficult time determining the primary abuser or that the assaultive behavior is actually a domestic crime. Access to services is severely limited by lack of shelters that serve male victims. Sensitivity to the needs of this group is paramount to effecting social change and helping victims receive needed assistance (Sanctuary for Families, 2014; NCAVP, 2012).
Domestic violence has an enormous impact on the health of those who are affected as well as on the healthcare system.
One in 4 women and 1 in 7 men aged 18 and older in the United States have been the victim of severe physical violence by an intimate partner in their lifetime. Nearly 15% of women and 4% of men have been injured as a result of acts of domestic violence that included rape, physical violence, and/or stalking by an intimate partner in their lifetime (Black et al., 2011).
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 professionals to ask about IPV, especially in older adult patients (Zink et al., 2005).
Children who are subjected to domestic violence develop problems such as attachment disorder, depression, anxiety, and oppositional defiance disorder. A violent environment will have the greatest adverse effects on the brains of the youngest children, even infants. This is because the developing brain of a child is highly sensitive, and the chronic state of fear and stress that these children experience prevents the brain from developing normally. Instead, the brain is influenced adversely by abnormal patterns of neurological activities and brain chemicals (Perry, 2009).
The Adverse Childhood Experience (ACE) Study, published in 2009, investigated the association between childhood maltreatment and later-life health and wellbeing (CDC, 2009). The ACE Study findings suggest that child maltreatment experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. The more adverse childhood experiences that were experienced by an individual, the greater the risk of developing alcoholism, chronic obstructive pulmonary disease (COPD), depression, illicit drug use, intimate partner violence, sexually transmitted infections, criminality, and smoking.
(See also “First Impressions: Exposure to Violence and a Child’s Developing Brain,” listed in the “Resources” section at the end of this course.)
The National Institutes of Health published a systematic review of risk factors for IPV (Capaldi, 2012). They include:
Although domestic violence is found in all walks of life, those who live in poverty face additional challenges. Poverty damages health and wellbeing in countless ways; exposure to domestic violence is just one. 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.
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. For instance, research shows that domestic violence is a primary cause of homelessness for women and families. A study in Massachusetts showed that 63% of homeless women were survivors of IPV (National Alliance to End Homelessness, 2014).
Kentucky launched a housing program, KDVA Homes, in 2011 to remedy this problem. The Kentucky Domestic Violence Association (KDVA) also provides the Economic Empowerment Project, which includes financial education, credit counseling, tax preparation, and the opportunity to open individual development accounts to help survivors save toward a specific goal (KDVA, 2014).
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 poorly 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. These families respond to tension or conflict with violence because they have not learned any other way to respond.
IPV often begins or escalates during pregnancy, making pregnancy an especially dangerous time for women in abusive relationships. Any type of abuse during pregnancy increases the risk of health problems for the woman and the unborn child because a pregnant woman is particularly vulnerable both physically and emotionally. Trauma from physical abuse can cause a woman both acute injury and increase her risk for an obstetrical emergency, preterm birth, complications during labor, or miscarriage later in the pregnancy (NDVH, 2013).
In 2012, there were 94 counts of pregnancy-associated suicide and 139 counts of pregnancy-associated homicide in the United States. These deaths confirm the need to evaluate IPV with pregnancy-associated violent death (Palladino, 2011).
Battering can lead to high blood pressure or edema, vaginal bleeding, kidney or urinary tract infection, miscarriage, preterm labor, low birth-weight, 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.
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).
According to research, women with a disability are more likely to experience IPV than those without a disability. In fact, 37.3% of women with a disability reported experiencing some form of IPV during their lifetime as compared to 20.6% of women without a disability (CDC, 2012).
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.
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 of escalation in domestic violence. The time of separation—when an abuse victim leaves the abuser and just afterward—presents the greatest threat to the abuser’s ability to maintain power and control.
The top five risk factors for homicide are:
A number of other factors have been identified as contributing to increased threat of lethality in an abusive situation (KBN, 1997; NMJEC, 2005):
Saltzman and colleagues (2002) identify four types of IPV:
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.
Physical violence can be defined 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” (Saltzman et al., 2002).
As described by Saltzman and colleagues (2002), sexual violence has three categories:
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 study of women ages 16–29 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 both physical and sexual violence include the use of “words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm” (Saltzman et al., 2002).
Kentucky statutes 510.040, 510.050, and 510.060 describe the crime of rape, in which a person engages in sexual intercourse with another person by forcible compulsion, or engages in sexual intercourse with another person who is incapable of consent due to being physically helpless, of poor mental capacity, or a young age.
Kentucky statute 510.110 describes the crime of sexual abuse, in which a person subjects another person to sexual contact by forcible compulsion, including those who are incapable of consent due to being physically helpless, of poor mental capacity, or a young age.
Psychological/emotional violence “involves trauma to the victim caused by acts, threats of acts, or coercive tactics” (Saltzman et al., 2002). 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).
The Bureau of Justice’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 stalking victims as 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 76% 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).
KRS 508.130 defines stalking as engaging in an intentional course of conduct which:
According to Kentucky statute 508.140, a person is guilty of the felony of stalking in the first degree who intentionally:
According to Kentucky statute 508.150, a person is guilty of the misdemeanor of stalking in the second degree who intentionally:
“Each January, we draw attention to a crime that will affect 1 in 6 American women at some point in their lives. Although young women are disproportionately at risk, anyone can be a victim of stalking—regardless of age, sex, background, or gender identity. While many victims are stalked by ex-partners, sometimes the perpetrators are acquaintances or even strangers. During National Stalking Awareness Month, we extend our support to victims and renew our commitment to holding their stalkers accountable.
“Stalkers seek to intimidate their victims through repeated unwanted contact, including harassing phone calls, text messages, or emails. Cyberstalking is increasingly prevalent, with more than one quarter of stalking victims reporting being harassed through the Internet or electronically monitored. Many victims suffer from anxiety, depression, and insomnia, and some are forced to move or change jobs. Stalking all too often goes unreported, yet it also tends to escalate over time, putting victims at risk of sexual assault, physical abuse, or homicide.”
—President Barack Obama (2013)
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 oneself 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 14–24 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 are 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.
Although there is no universally accepted definition of cyberstalking, the term is used here to refer to the use of the Internet, e-mail, or other electronic communications devices to stalk another person. Cyberstalking has become an all-too-common means of harassment, particularly by spurned intimate partners. Even though cyberstalking does not involve physical contact with the perpetrator, it can constitute emotional and psychological abuse.
The Stalking Resource Center recommends that victims of cyberstalking:
In August 2013, Alisha Waters was shot five times by her former husband. Although she survived, she was left a quadriplegic after the assault. During the two weeks prior to the shooting, her ex-husband texted her 186 times. She requested an emergency protection order against him, but her request was denied because at that time cyberstalking was not grounds for a domestic violence protection order in Kentucky (Hall, 2013). Kentucky’s stalking statute (KRS 508.130) has since been amended to include cyberstalking.
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.
Although an abuser’s behavior may also 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 assessing high-risk individuals.
A model developed by the Domestic Abuse Intervention Project 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 a male abuser uses to intentionally control or dominate his intimate partner. These actions fall under eight primary categories:
(See also “Resources” at the end of this course.)
Source: DAIP, 1984.
Anthony and Deborah met in their early twenties. Anthony’s source of income was an inheritance, and Deborah was completing a nursing program. After Deborah graduated, they married and Deborah began working at a local hospital. She was unhappy that she had to go to work and Anthony did not. When Deborah complained about the situation, Anthony spat on her and told her that his inheritance was only for him and that she needed to earn enough money to pay for her own support.
Deborah became pregnant and worked the night shift after the baby was born. Following the birth of a second child two years later, Deborah asked Anthony to get a job. He declined, arguing that he was taking care of the children and she could make more money than he could. Anthony did not allow Deborah access to either the checkbook or a credit card.
One morning, Deborah’s car was towed away because the car payments were in arrears. Anthony told her she would have to take the bus. When she again asked Anthony to get a job, he became angry, yelling and shoving and even throwing a chair at her during the argument. When Deborah told Anthony that she wanted a divorce, he threatened to take the children away forever. Deborah was ashamed to ask her friends or family for help and remained in the marriage for several more years until Anthony began to physically abuse the children.
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 fall into three broad categories: situational factors, emotional factors, and personal beliefs. 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.
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:
Source: Oregon Counseling, 2013.
Every healthcare facility that serves women, children, and older adults needs to screen for potential domestic violence. This screening need not be lengthy. The screening can be part of the intake interview or included as part of the written history. 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 professionals should be alert for signs and symptoms that may be related to domestic violence:
The Danger Assessment Instrument is an excellent tool and has been used for over 25 years by health professionals, law enforcement, and advocates. The tool consists of 20 questions that the client may respond to with yes/no answers. The various questions are weighted for risk factors associated with intimate partner homicide. Some of the risk factors include past death threats, partner’s employment status, and partner’s access to a gun. The tool is available online for certified professionals to download after they have completed a brief online training and post-test. (See “Resources” at the end of this course.)
Source: Campbell, 2003.
During the physical examination:
Following an established procedure for examination will ensure that no critical information is overlooked:
It is important to remember that many victims of domestic violence may show no signs of injury at all. Non-fatal strangulation, which can be a strong predictor of future homicide, may leave no marks. Sexual assault may result in no trauma. In fact, there may be no physical signs resulting from the top five predictors of lethality: threatening to use a weapon, threatening to kill the victim, constant jealousy, strangulation, and forced sex.
Strangulation is one of the most lethal forms of domestic violence: unconsciousness may occur within 10 seconds and death within 4 minutes. Strangulation is also one of the best predictors for future homicide of victims of domestic violence. One study showed that “the odds of becoming an attempted homicide increased by about seven-fold for women who had been strangled by their partner” (Glass, 2008). Yet strangulation has been overlooked in the medical literature, and many states still do not adequately address this violence in their criminal statutes.
Many victims of strangulation do not seek medical attention because “they look fine.” When law enforcement officers respond to emergency calls, they may think the same, because in the majority of cases there are no visible signs.
While victims of strangulation may have no visible injuries, the lack of oxygen during the assault can cause serious trauma to the brain and lead to death days, or even weeks, later. Strangulation can have a devastating psychological effect on victims in addition to a potentially fatal outcome, including suicide.
In some cases, injuries may be apparent. A strangulation victim may struggle violently, which could lead to neck injuries. Efforts to fight back may also lead to injury on the face or hands of the assailant. Victims of strangulation may also experience difficulty breathing, speaking, or swallowing; nausea; vomiting; light headedness; headache; and involuntary urination and/or defecation (Training Institute on Strangulation Prevention, 2014).
(See also “Resources” at the end of this course.)
Women who show signs of physical abuse should also be screened for sexually transmitted infections (STIs), including chlamydia, human papilloma virus, gonorrhea, trichomoniasis, bacterial vaginitis, and syphilis. One study found that approximately 64% of rural women with an STI 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.
Even though many healthcare professionals are alert to signs of potential child abuse, too few screen for domestic violence among adults.
One third of U.S. physicians surveyed said that they do not record patients’ reports of domestic violence and 90% do not document whether patients are offered information or other support. One third of physicians surveyed stated 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% in people over age 60 (Acheron et al., 2010), only 2% of reported elder abuse cases come through physicians. In Maryland, one quarter of prehospital care providers surveyed defined elder abuse as a social problem, not a medical problem. Likewise, one third of respondents indicated they would suspect dementia, depression, or other reasons rather than abuse for a report of sexual assault in an elderly patient (Rinker, 2009).
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):
A documentation form for mandated reporters is helpful to prompt the clinician to include all of the necessary information.
Health professionals should document the history of a person who has disclosed injuries as a result of domestic violence using the same language as for any patient.
When assessment and examination are complete, review any therapeutic protocols with the patient and provide a supportive and encouraging environment in which the patient can seek help and get support. Be prepared to:
It is also critical to understand and implement the facility’s established safety protocols.
Mandatory reporting of spouse abuse, child abuse, and abuse of those adults unable to protect themselves, such as the elderly or persons with a disability, is required by all persons in Kentucky and is not limited to health professionals. Any person having reason to believe that a married person of any age has been abused or neglected by their spouse must report it to the Cabinet for Health and Family Services (CHFS). The Cabinet, in turn, is required to notify the appropriate law enforcement agency.
Kentucky statute specifically requires all healthcare professionals to provide an oral or written report to the CHFS when they suspect abuse, neglect, or exploitation. Certainty is not required to make a confidential report, nor is the consent of the patient.
A report of spouse abuse will result in notification to law enforcement and may result in an investigation, arrest, and prosecution of the abuser. It is important that victims be made aware of this, because they may have no control over what will occur within the various systems.
There is no law in Kentucky that requires a mandatory report of domestic violence unless the partners are married. However, the Cabinet will accept any reports of domestic violence involving unmarried persons and offer services to victims without regard to marital status. Those reports may or may not be forwarded to law enforcement (KDVA, 2014).
Any life-threatening situation should be reported to the police immediately by calling 911.
Furthermore, there are four ways to report domestic violence to the Cabinet for Health and Family Services:
A domestic violence documentation form (MS Word document) for healthcare professionals is available from the Kentucky Cabinet for Health and Human Services website.
Donna, an office nurse in a busy OB/GYN practice in Kentucky, noted multiple bruises in various stages of healing on her patient Brandy’s legs during a routine prenatal visit. Donna asked Brandy about the bruises, and Brandy stated they were the result of her husband kicking her. Brandy did not want to report the incident to the police, but Donna told her that she is required by law to notify the Cabinet for Health and Family Services and that the police would be contacting Brandy. Donna gave Brandy a resource pamphlet on domestic violence and made a telephone report to the Cabinet immediately after Brandy’s appointment.
In the case of spousal abuse, the Kentucky Revised Statute 209A.030 mandates that:
Any person, including, but not limited to, physician, law enforcement officer, nurse, social worker, cabinet personnel, coroner, medical examiner, alternate care facility employee, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter. Death of the adult does not relieve one of the responsibility for reporting the circumstances surrounding the death.
An oral or written report shall be made immediately to the Cabinet upon knowledge of the occurrence of suspected abuse, neglect, or exploitation of an adult. Any person making such a report shall provide the following information, if known: the name and address of the adult, or of any other person responsible for his care; the age of the adult; the nature and extent of the abuse, neglect, or exploitation, including any evidence of previous abuse, neglect, or exploitation; the identity of the perpetrator, if known; the identity of the complainant, if possible; and any other information that the person believes might be helpful in establishing the cause of abuse, neglect, or exploitation.
Upon receipt of the report, the Cabinet shall take the following action as soon as practical:
- Notify the appropriate law enforcement agency;
- Initiate an investigation of the complaint; and
- Make a written report of the initial findings together with a recommendation for further action, if indicated.
In addition to mandatory reporting requirement laws, Kentucky nurses and other healthcare professionals should keep themselves informed of the current status of related statutes. Establishing good communication with local law enforcement and judicial offices in order to stay abreast of any changes is also recommended.
Healthcare workers may report spousal abuse to Adult Protective Services (APS) when a patient with dementia exhibits violent behavior, but if the violence is dementia-related and the client is receiving dementia care services, there may be nothing more that the APS worker can do. It may be prudent to attempt to have guns and other obvious weapons removed from the home or to notify the police.
There is a need for dementia care programs to develop policies for situations that involve clients who have histories of domestic violence. These policies should address how to assess future risk and what to do to ensure caregivers’ safety. Working with law enforcement to safeguard that violent elders with dementias are treated humanely is also important. Elder abuse is now being incorporated into domestic violence policies, and police are being instructed to use applicable domestic violence laws when responding to elder abuse cases.
Involving the police may result in more elders with dementias becoming incarcerated. Some people in the dementia care field are concerned that inappropriate actions (such as incarceration of a confused elder) may result from the interactions between law enforcement and Adult Protective Services. Cognitive decline is usually gradual, making it difficult to determine at which point people are no longer culpable for their actions. A response that is both fair and humane will require cooperation between law enforcement and adult protective services (Nerenberg, 2006).
On July 19, 2012, 77-year-old Rosetta Rosa shot and killed her husband of 54 years because she said he was sexually abusing their granddaughter. The granddaughter was not present at the time of the shooting. For the next two days after killing him, Ms. Rosa continued to prepare meals for her husband. Ms. Rosa underwent a series of interviews with psychiatrists and was found to be incompetent to stand trial due to progressive and irreversible dementia. The murder charge was dismissed in August of 2013. While in court for the hearing, Ms. Rosa asked if her husband was present (Hefler, 2013).
Healthcare professionals can begin by believing any patient who indicates she or he is being abused. The patient 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 an 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 professionals 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.
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 safely in the relationship. Provide information about available resources, such as hotline and shelter numbers. Suggest she pack a quick getaway bag with personal items to be hidden or left with a trusted neighbor or friend. Recommend she 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.
When leaving the home because of abuse, abuse victims with children should take their children with them to prevent them from being abused or held hostage by the abuser. For example, a mother can have her children go to bed with their shoes on so they can escape at a moment’s notice if their alcoholic father becomes violent. She can train them to run to a trusted neighbor’s and ask them to call the police.
Children living with an abuser 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. There are downloadable and printable forms available online from the website of the Kentucky Domestic Violence Association (see “Resources” at the end of this course). The website provides a detailed discussion of the elements of a safety plan, along with forms that a victim can use to begin preparing both physically and psychologically to escape an 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 should also use the following questions to evaluate immediate safety issues:
A protective order is a document that is signed by a judge and informs the abuser to stop the abuse or face serious legal consequences. A protective order can be issued to both male and female victims of domestic violence.
There are two types of civil protective orders:
In Kentucky, a protective order will not be granted to a victim if the abuser is a boyfriend or girlfriend and they have never lived together or do not have a child together.
In Kentucky, protective orders are issued under the civil law system. When a victim asks the court for protection from the abuser, the victim is not asking the court to arrest that person for committing a crime. But if the abuser violates the civil court order of protection, he may then be sent to jail. In a civil case, the victim has the right to drop the case.
The criminal law system handles all cases that involve crimes such as assault, harassment, theft, etc. A criminal complaint involves the abuser being charged with a crime. In a criminal case, the district attorney is the one who can decide to drop the case and the victim does not have any control over whether or not the case continues (WomensLaw.org, 2008).
It is critical in any clinical setting to develop protocols that assist and support staff when caring for victims of domestic violence. A protocol enables the staff to respond to domestic violence in a comprehensive and consistent manner. Any protocol should include screening, identification/assessment, treatment, documentation, safety planning, discharge planning, and referral. A protocol can be comprehensive or brief, but it should adequately provide the staff with a blueprint for preparing for and responding effectively and efficiently to patients experiencing domestic violence.
The minimal elements that should be included are:
The YWCA in Louisville opened Kentucky’s first spouse abuse shelter in 1977. Shortly thereafter, in 1981, the Kentucky Domestic Violence Association (KDVA) was founded as a statewide coalition whose members included all domestic violence programs in the state. The purpose of the coalition is to provide mutual support, information, resource sharing, and technical assistance; to coordinate services; and to collectively advocate for battered women and their children on statewide issues.
Working together with the Department for Social Services, KDVA helped establish a domestic violence program in each of Kentucky’s 15 multi-county Area Development Districts (ADDs). Kentucky now has a regionalized network of 15 state-funded spouse abuse centers with shelter capacity for hundreds of people (KDVA, 2008).
Spouse abuse centers provide a variety of related support services to residents and nonresidents that include:
KDVA is also a leader in efforts to prevent future domestic violence through public awareness and community education efforts. It works together with schools, local professionals, and community groups to increase understanding of domestic violence issues. KDVA and its members have also worked to help pass legislation related to domestic violence, such as laws addressing warrantless arrest, emergency protective orders, and marital rape, to name a few.
Kentucky’s Crime Victims Compensation Board (CVCB) also provides victims with crime compensation funds, assisting more than 1,000 victims of violent crime per year who have no other resources to pay for the medical, funeral, counseling, dental, or other expenses resulting from the crime. Assistance also provides for lost wages of the victim or loss of support for someone dependent on the victim (CVCB, 2011).
Prevention of domestic violence and early identification and treatment of victims eliminates much pain and suffering for survivors and benefits all healthcare systems in the long run.
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 professionals may be able to do one or more of the following:
Domestic violence, in any form, diminishes human beings. Children, the future of our society, are all too often witnesses of this abuse and suffer irreparable damage from the exposure. Healthcare professionals can make a critical difference in 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, cultural, and socioeconomic group, nurses can identify, protect, and assist victims in resolving their situations.
To accomplish this goal, nurses must be present for their patients, learn to ask the right questions, and help be the voice for those who are too afraid to ask for help. Healthcare professionals must put forth a coordinated effort with advocacy groups, community resources, and law enforcement in order to be effective change agents.
Dating Matters (60-minute interactive training on teen dating violence)
National Domestic Violence Hotline
Rape, Abuse, and Incest National Network (RAINN)
Spouse Abuse Shelter Hotline
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, & Kilpatrick DG. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the national elder mistreatment study. American Journal of Public Health, 100(2), 292–7.
Associated Press-MTV. (2009). A thin line: 2009 AP-MTV digital abuse study. Retrieved from http://www.research.ATHINLINE.org
Black MC, Basile KC, Breiding MJ, Smith SG, Watlers ML, Merrick MT, Chen J, Stevens MR. (2011). National Intimate Partner and Sexual Violence Survey (NISVS) summary report 2010. Retrieved from http://www.cdc.gov
Bureau of Justice Statistics (BJS), U.S. Department of Justice. (2006). Supplemental victimization survey, 2006. Retrieved from http://bjs.ojp.usdoj.gov
California Clinical Forensic Medical Training Center (CCFMTC). (2014). Forensic photography: documentation of the physical effects of violence. Participant manual. Sacramento: Author.
Campbell JC. (2003). Danger assessment. Retrieved from http://www.dangerassessment.org
Campbell JC, Jones AS, Dienemann J, et al. (2002). Intimate partner violence and physical health consequences. Archives of Internal Medicine, 162, 1157–63.
Capaldi DM, Knoble NB, Shortt JW, Kim HK. (2012). A systematic review of risk factors for intimate partner violence. Partner Abuse, 3(2), 231–80. doi:10.1891/1946-65184.108.40.206.
Centers for Disease Control and Prevention (CDC). (2012). Intimate partner violence. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2009). Adverse Childhood Experience (ACE) study. Retrieved from http://www.cdc.gov
Cho H. (2012). Use of mental health services among Asian and Latino victims of intimate partner violence. Violence Against Women, 18(4), 404–19. Retrieved from http://vaw.sagepub.com
Clifford, A. (2003). Intimate partner violence in rural women. Kentucky Nurse, 51(4), 9.
Coker A, Smith, P, Bethea L, et al. (2000). Physical health consequences of physical and psychological intimate partner violence. Archives of Family Medicine, 9(5), 451–7.
Colorado Department of Human Services (DHS). (2010). Domestic violence annual report 2010. Retrieved from http://www.colorado.gov.
Cooper C, Selwood A, Blanchard M, Walker Z, Blizard R, & Livingston G. (2009). Abuse of people with dementia by family carers: representative cross sectional survey. British Medical Journal, 338, b155.
Crime Victims Compensation Board of Kentucky. (2011). Victim compensation program. Retrieved from http://cvcb.ky.gov
Domestic Abuse Intervention Project (DAIP). (1984). Power and control wheel. Retrieved from http://www.theduluthmodel.org
Dutton MA. (2009). Pathways linking intimate partner violence and posttraumatic disorder. Trauma, Violence and Abuse, 10(3), 211–24.
Family Violence Prevention Fund. (2008). Features: study: many victims of partner violence experience reproductive coercion. Retrieved from http://www.endabuse.org
Gerber MR, Leiter KS, Hermann RC, et al. (2005). How and why community hospital clinicians document a positive screen for intimate partner violence: a cross-sectional study. BMC Family Practice. doi:10.1186/1471-2296/6/48.
Glass N, Laughon K, Taliaferro E. (2008). Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Medicine, 35(3), 329–35. doi:10.1016/j.jemermed.2007.02.065.
Goodman LA, Smyth KF, Borges AM, Singer R. (2009). When crises collide: how intimate partner violence and poverty intersect to shape women’s mental health and coping? Trauma, Violence and Abuse, 10(4), 306–29.
Hefler J. (2013).Woman with Alzheimer’s won’t be tried in husband’s killing. The Inquirer (August 21). Retrieved from http://articles.philly.com
Heise L & Garcia-Moreno C. (2002). Violence by intimate partners. In E Krug, L Dahlberg, J Mercy, et al. (eds.), World Report on Violence and Health. Geneva: WHO.
Holtz H & Furniss KK. (1993). The health care provider’s role in domestic violence. Trends in Healthcare Law and Ethics, 15, 519–22.
Isaac NE & Enos VP. (2001). Documenting domestic violence: how healthcare providers can help victims. Washington DC: National Institute of Justice. Retrieved from http://www.ncjrs.org
Kendall-Tacket KA. (2007). Violence against women and the perinatal period: the impact of lifetime violence and abuse on pregnancy, postpartum and breastfeeding. Trauma, Violence and Abuse, 8(3), 34–5.
Kentucky Board of Nursing (KBN). (1997). Model curriculum for domestic violence training. Louisville, KY: author. Retrieved from http://kbn.ky.gov
Kentucky Domestic Violence Association (KDVA). (2014). Economic Justice Project. Retrieved from http://www.kdva.org
Kentucky Domestic Violence Association (KDVA). (2008). History. Retrieved from http://www.kdva.org
Kentucky Domestic Violence Association (KDVA). (2006). KDVA update: newsletter of the Kentucky Domestic Violence Association, October. Retrieved from http://www.kdva.org
Kentucky State Police (KSP). (2012). Crime in Kentucky 2012. Retrieved from http://www.kentuckystatepolice.org
McFarlane JM, Campbell JC, Wilt S, Sachs CJ, Ulrich Y, Xu X. (1999). Stalking and intimate partner femicide. Homicide Studies, 3(4), 300–16.
Miller E, Decker MR, McCauley HL, Tancredi DJ, Levenson RR, et al. (2010). Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception, 81(4), 316–22. Epub2010 Jan. 27.
National Alliance to End Homelessness. (2014). Retrieved from http://www.endhomelessness.org
National Center for Victims of Crime (NCVC). (2003). Cyberstalking. Retrieved from http://www.ncvc.org
National Center on Elder Abuse (NCEA). (2012). Elder abuse: the size of the problem. Retrieved from http://www.ncea.aoa.gov
National Coalition of Antiviolence Programs (NCAVP). (2012). Special issues in LGBT domestic violence. Retrieved from http://www.ncavp.org
National Domestic Violence Hotline. (NDVH). (2013). Pregnancy and abuse. Retrieved from http://www.thehotline.org
National Immigrant Justice Center (NIJC). (2013). Pro bono attorney manual on immigration relief for crime victims: U visas. Retrieved from http://immigrantjustice.org
National Resource Center for Victims of Crime (NRCVC). (2014). Stalking resource fact sheet. Retrieved from http://www.victimsofcrime.org
Nerenberg L. (2006) Perpetrators with dementia. Prevent Elder Abuse (August). Retrieved from http://preventelderabuse.blogspot.com
New Mexico Judicial Education Center (NMJEC). (2005). Lethality factors, in New Mexico domestic violence bench book. Albuquerque: Author. Retrieved from http://women.unm.edu
Nosek MA, Foley CC, Hughes RB, et al. (2001). Vulnerabilities for abuse among women with disabilities. Sexuality and Disability, 19, 177–90.
Obama B. (2013). Presidential proclamation. Retrieved from http://www.whitehouse.gov
Oregon Counseling. (2013). About domestic violence against men. Retrieved from http://www.oregoncounseling.org
Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol, 118(5), 1056–63. doi:10.1097/AOG.0b013e31823294da.
Perry, BD. (2009). Examining child maltreatment through a neurodevelopmental lens: clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14, 240–55. doi:10.1080/15325020903004350.
Plichta SB. (2004). Intimate partner violence and physical health consequences: Policy and practice implications. Journal of Interpersonal Violence, 19, 1293–6.
Rinker Jr. AG. (2009). Recognition and perception of elder abuse by prehospital and hospital-based care providers. Archives of Gerontology and Geriatrics, 48(1), 110–5.
Roehl J, O’Sullivan C, Webster D, Campbell J. (2005). Intimate partner risk assessment validation study, final report, document #209731, submitted to the U.S. Dept. of Justice. Retrieved from https://www.ncjrs.gov
Saltzman LE, Fanslow JL, McMahon PM, et al. (2002). Intimate partner violence surveillance: uniform definitions and recommended data elements. Atlanta: CDC, National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov
Sanctuary for Families. (2014). Domestic violence and LGBT community. Retrieved from http://www.sanctuaryforfamilies.org
Seff LR, Beaulaurier RL, Newman FL. (2008). Nonphysical abuse: findings in domestic violence against older women study. Journal of Emotional Abuse, 8(3), 355–74.
Silverman JG, Decker MR, Reed E, Raj A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195(1), 140–8.
Smith DL & Strauser DR. (2008). Examining the impact of physical and sexual abuse on the employment of women with disabilities in the United States: an exploratory analysis. Disability and Rehabilitation, 30(14), 1039–46.
Society of Obstetricians and Gynaecologists of Canada (SOGC). (2005). Women’s health information: intimate partner violence. Retrieved from http://www.sogc.org
Tjaden P & Thoennes N. (2000). Extent, nature and consequences of intimate partner violence: findings from the national violence against women survey. Washington DC: U.S. Department of Justice. Retrieved from http://www.ojp.usdoj.gov
Training Institute on Strangulation Prevention. (2014). Strangulation documentation forms. Retrieved from http://www.strangulationtraininginstitute.com/index.php/library/finish/837-documentation-forms/3634-documentation-char-for-non-fatal-strangulation-cases.html and http://www.strangulationtraininginstitute.com
U.S. Department of Homeland Security (U.S. DHS). (2014). U visa. Retrieved from http://www.uscis.gov
U.S. Department of Justice, Office on Violence against Women. (2010). About domestic violence. Retrieved from http://www.ovs.usdoj.gov
Walker L. (1984). The battered woman syndrome. New York: Springer. Retrieved from http://nystudios.files.wordpress.com
Warshaw C. (1995). Improving the healthcare response to domestic violence. Retrieved from http://www.futureswithoutviolence.org
Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, & Fitzgerald W. (2010). Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 58(3), 493–500.
Women’sLaw.org. (2008). Kentucky statutes. Retrieved from http://www.womenslaw.org
Women’s Rural Advocacy Programs (WRAP). (2007). Why women stay: the barriers to leaving. Retrieved from http://www.letswrap.com
Zink T, Fisher BS, Regan S. (2005). The prevalence and incidence of intimate partner violence in older women in primary care practices. Journal of General Internal Medicine, 20, 884–8.