Domestic Violence Education
COURSE PRICE: $24.00
CONTACT HOURS: 3
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Provider approved by the California Board of Registered Nursing, Provider #12300.
Course Availability: Expires April 3, 2017. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc., provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Medical Disclaimer Legal Disclaimer Disclosures
Domestic Violence Education
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to educate healthcare professionals on the dynamics of domestic violence, including the effects on adult and child victims, lethality and risk issues, legal remedies for protection, community resources and victim services, reporting requirements, and model protocols for addressing domestic violence.
Upon completion of this course, you will be able to:
- Describe who is affected by domestic violence.
- Discuss the healthcare implications of domestic violence.
- List common risk factors and lethality issues for domestic violence.
- Identify the dynamics associated with the different types of domestic violence.
- Recognize the signs and symptoms of domestic violence.
- Discuss appropriate documentation in cases of suspected domestic violence.
- Describe actions to protect victims of domestic violence.
- Explain a model protocol that addresses domestic violence.
TABLE OF CONTENTS
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:
- Criminal coercion
- Unlawful imprisonment
- Sexual assault, rape
- Manslaughter, murder
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.
DOMESTIC VIOLENCE TERMINOLOGY
Various terms are used to refer to domestic violence. The Centers for Disease Control and Prevention (CDC) often uses the more specific term intimate partner violence (IPV) when referring to harm to a current or former partner or spouse. Other agencies prefer the term domestic abuse because it highlights 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.
WHO IS AFFECTED BY DOMESTIC VIOLENCE?
“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 among Women
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.
Teens and Dating Violence
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:
- Trauma symptoms
- Exposure to harsh parenting
- Exposure to inconsistent discipline
- Lack of parental supervision and warmth
- Belief that using dating violence is acceptable
- Alcohol use
- Behavioral problems in other areas
- Having a friend involved with dating violence
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).
Domestic Violence among Older Adults
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 in Diverse Cultural and Ethnic Groups
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.
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.
LGBTQI Community and Domestic Violence
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:
- An LGBTQI victim may fear that the abuser will reveal his or her sexual orientation or biological gender to family, friends, or coworkers.
- Abusers may threaten to reveal an infected person’s positive HIV status to others or to transmit HIV to the victim if he or she is HIV negative.
- These individuals fear institutional discrimination and homophobic or transphobic care providers.
- A transgender person may not have undergone sexual re-assignment surgery and may avoid a physical exam by a clinician that might include observation of his or her genitals.
Law enforcement authorities may not recognize same sex individuals as intimate partners and 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).
Health Effects of Domestic Violence
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).
HEALTH EFFECTS ON CHILDREN
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.)
RISK FACTORS AND LETHALITY
Common Risk Factors
The National Institutes of Health published a systematic review of risk factors for IPV (Capaldi, 2012). They include:
- Low self-esteem
- Age range in adolescence and young adulthood
- Unemployment and low income
- Minority group membership
- High levels of acculturation stress
- Financial and work-related stress
- Lack of parental support and/or monitoring in adolescents
- Adolescent involvement with aggressive peers
- Social isolation
- Conduct problems
- Depression and irritability
- Substance use
- Low relationship satisfaction
- Childhood victimization
- Exposure to interparental violence
- Alcohol use
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.
- 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. 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).
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.
Risk of Lethality
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:
- The abuser has threatened to use or has used a gun, knife, or other weapon on the victim.
- The abuser has threatened to kill the victim.
- The abuser has strangled the victim.
- The abuser is violently or constantly jealous.
- The abuser has forced the victim to have sex.
A number of other factors have been identified as contributing to increased threat of lethality in an abusive situation (KBN, 1997; NMJEC, 2005):
- Children in the home, especially if not those of the abuser
- Threats to kill the partner or children
- Availability of weapons
- Alcohol or drug dependency
- Escalating violence or risk taking
- Obsessive behavior by abuser (“If I can’t have you, nobody will”)
- Depression or other mental illness
- Extended history of violence
- Other antisocial behavior outside the home
- Hostage taking, preventing partner from leaving the house
- History of violence in family of origin
- Cruelty to animals
WHAT DOES DOMESTIC VIOLENCE LOOK LIKE?
Saltzman and colleagues (2002) identify four types of IPV:
- Physical violence
- Sexual violence
- Threats of physical or sexual violence
- Psychological/emotional violence
Research indicates that intimate partner violence (IPV) occurs in a three-phase cycle (Walker, 1984):
- A period of increasing tension, leading to
- The violence, followed by
- A “honeymoon” period of calm and remorse in which the abuser is kind and loving and begs for forgiveness
When stress and conflict begin to build, the cruel cycle begins again. Over time, the first two phases grow longer and the honeymoon phase diminishes and eventually disappears.
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:
- 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
- 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
- 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 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).
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:
- Receiving unwanted phone calls
- Receiving unsolicited or unwanted letters or e-mails
- Being followed or spied on
- Having the stalker show up at places without a legitimate reason
- Having the stalker wait at places for the victim
- Receiving unwanted items, presents, or flowers
- Having information or rumors about the victim posted on the Internet, in a public place, or by word of mouth
Although these acts individually may not be criminal, collectively and repetitively they may cause a victim to fear for his or her safety or the safety of a family member.
Stalking often precedes murder or attempted murder of women by their intimate partners (femicide). Researchers reported that 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).
STALKING AWARENESS MONTH
“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:
- Do not discount their instincts
- Call the police if there is immediate danger and explain why certain actions cause fear
- Keep a record of each contact and save all e-mails, text messages, photos, and other communications
- Connect with a local advocate to discuss options and a safety plan
- Call the National Domestic Violence Hotline (see “Resources” at the end of this course)
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 her state (Hall, 2013). In response, the legislature amended the state’s stalking statute to include cyberstalking.
Why Perpetrators Abuse
People outside of abusive relationships often wonder both why a perpetrator abuses and why a victim of abuse remains in such a relationship. 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.
POWER AND CONTROL
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:
- Using coercion and threat
- Using intimidation
- Using emotional abuse
- Using isolation
- Minimizing, denying, and blaming
- Using children
- Using male privilege
- Using economic abuse
(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.
Why Victims Stay
There are many reasons why victims stay in abusive relationships, and in any given relationship there may be numerous factors that form an interrelated web. These reasons 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.
- Economic dependence and inability to support herself and her children
- Fear of greater physical danger to herself and her children if they try to leave
- Fear of being hunted down and suffering a worse beating than before
- Fear of being killed if she leaves, often based on real threats by her partner
- Fear of emotional damage to the children
- Fear of losing custody of the children, often based on her partner’s remarks
- Lack of alternative housing; nowhere else to go
- Lack of job skills or the inability to get a job
- Social isolation resulting in lack of support from family and friends
- Social isolation resulting in lack of information about her alternatives
- Lack of understanding from family, friends, police, ministers, etc.
- Negative responses from community, police, courts, social workers, etc.
- Fear of involvement in the court process, sometimes due to bad prior experiences
- Fear of the unknown (“Better the devil you know than the devil you don’t”)
- Fear and ambivalence over making formidable life changes
- “Acceptable violence,” in which the violence escalates slowly over time and numbs the victim so that she is unable to recognize a pattern of abuse
- Fear of losing ties to the community, including the children leaving their school, leaving behind friends and neighbors, losing contact with her “old life”
- Ties to her home and belongings
- Family pressure (“Mom always told you it wouldn’t work out,” or “You made your bed, now sleep in it”)
- Fear of her abuser doing something to “get” her (reporting her to welfare, calling her workplace, etc.)
- Inability to access resources due to language barriers, disability, homophobia, etc.
- Lack of time needed to plan and prepare to leave
- Insecurity about being alone or on her own; fear she can’t cope with home and children by herself
- Loyalty (“He’s sick; if he had a broken leg or cancer, I would stay. This is no different.”)
- Pity, feeling sorry for him
- Wanting to help (“If I stay, I can help him get better.”)
- Fear that he will commit suicide if she leaves, often based on her partner’s remarks
- Denial (“It’s really not that bad. Other people have it worse.”)
- Love, particularly when the abuser is quite loving and lovable when he is not being abusive
- Love, especially when remembering what he used to be like
- Guilt, believing that their problems are all her fault, often with the agreement of her partner
- Shame and humiliation in front of the community (“I don’t want anyone else to know.”)
- Unfounded optimism that the abuser will change
- Unfounded optimism that things will get better, despite all evidence to the contrary
- Learned helplessness, as a result of trying every possible method to change things without success, thereby coming to expect failure (also seen with prisoners of war, hostages, those in extreme poverty, etc.)
- False hope (“He’s starting to do things I’ve been asking for,” such as counseling, anger management, etc.)
- Feeling responsible, as though she only needs to meet some set of vague expectations in order to earn the abuser’s approval
- Insecurity over her potential independence and lack of emotional support
- Guilt about the failure of the marriage/relationship
- Demolished self-esteem (“Just like he says, I’m too fat, stupid, ugly, etc., to leave.”)
- Simple exhaustion, feeling too tired and worn out from the abuse to leave
- Parenting: that the children need two parents (“A crazy father is better than none at all.”)
- Religious and family: pressure to keep the family together no matter what
- Duty (“I swore to stay married till death do us part.”)
- Responsibility: it is up to her to work things out and save the relationship
- Belief in the American dream of growing up and living happily ever after
- Identity: being raised to feel that all women need a partner—even an abusive one—in order to be complete or accepted by society
- Violence: thinking all partners relate this way (often among women who experienced a violent childhood)
- Other religious and cultural beliefs
WHY ABUSED MEN STAY
While most victims of domestic violence are women, men are sometimes victims. Like women, men remain in these relationships for a variety of reasons. The most frequent seem to be:
- Protecting their children: afraid to leave their children alone with the abuser, that they will never be allowed to see their children again, that the abuser will turn the children against them
- Assuming blame (guilt-prone): believe that they deserve the abusive treatment or that it is their fault; feel responsible or that they can and should do something to fix things
- Dependency (or fear of independence): feel mental, emotional, or financial dependence on the abuser
Source: Oregon Counseling, 2013.
ASSESSMENT, DOCUMENTATION, AND TREATMENT
Assessing for Signs and Symptoms
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:
- Delay in seeking care or missed appointments
- Vague or inconsistent explanations of injuries or nonspecific somatic complaints
- Depression, chronic pain, and social isolation
- Substance abuse and use of alcohol or drugs
- Signs of abuse in pregnant clients (because abuse often escalates during pregnancy)
- Lack of eye contact and/or an intimate partner who is reluctant to leave the woman alone with the healthcare professional
- Patient who is fearful, anxious, withdrawn, angry, nonresponsive, or afraid to talk openly
- Suicide attempts
DANGER ASSESSMENT INSTRUMENT
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:
- 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 adults.
- Be aware that the patient may wear a glove or sock to conceal a scalded hand or foot.
Following an established procedure for examination will ensure that no critical information is overlooked:
- Have the patient change into an exam gown that will allow all areas of the body to be examined.
- Check for injuries.
- Document physical findings in detail and include measurements, preferably using a report form that is specified for domestic violence exams.
- Photograph injuries, including long-distance, mid-range, and close-up perspectives. Photograph each injury with and without a scale.
- Conduct a mental status exam.
- Use open, nonjudgmental questions regarding the mechanism of injury.
- Do not cut clothing or discard any potential evidence. Collect, preserve, and maintain chain of custody. All evidence should be stored in paper bags. Wet evidence should be placed inside of a waterproof container and given to law enforcement for immediate processing.
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 “Resources” at the end of this course.)
ASSESSING FOR OTHER CONDITIONS
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.
LACK OF SCREENING
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).
Documenting and Reporting Suspected Domestic Violence
Accurate, thorough documentation of the patient’s injuries is essential in cases of suspected abuse because it can serve as objective, third-party evidence useful in legal proceedings. For example, medical records can help victims to obtain a restraining order or to qualify for public housing, welfare, health and life insurance, and immigration relief.
To be admissible in a court of law, medical documentation should include the following (Isaac & Enos, 2001):
- Photographs of the injuries, taken during the initial examination
- Body maps, which document the extent and location of the injuries
- Description of the patient’s demeanor (crying, angry, agitated, upset), including a record of the patient’s comments about how the injuries occurred; the patient’s own words should be set off in quotation marks or identified by such phrases as “the patient states” or “the patient reports”
- Any description in which the patient identifies the abuser, such as “my boyfriend kicked me”
- The time of day when the patient is examined and, if possible, how much elapsed time since the injuries occurred; for example, “patient says that last night her husband punched her”
- Legible handwriting; poor handwriting on medical records can cause documentation to be deemed inadmissible as evidence
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.
- The clinician should avoid phrases—such as “patient claims” or “patient alleges”—that cast doubt on the patient’s reliability. For example, normal documentation of a chief complaint of abdominal pain is stated, “Patient states she has abdominal pain,” rather than, “Patient alleges she has abdominal pain.”
- The clinician should avoid legal terms such as alleged perpetrator or assailant. Instead, they should use the name of the person who inflicted the injuries, for example, “Patient states that Jack Smith, her ex-husband, struck her face with a closed fist.”
- Clinicians should document objectively and report facts rather than using conclusive terms such as assault and battery or domestic violence.
Most states require healthcare professionals and others to report suspected domestic abuse to state or local authorities. 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.
Donna, an office nurse in a busy OB/Gyn practice, 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 are 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 Department of Human Services and that the police would be contacting Brandy. Donna gave Brandy a resource pamphlet on domestic violence and made a telephone report immediately after Brandy’s appointment.
SPOUSAL ABUSE AND DEMENTIA
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).
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:
- Provide appropriate diagnostic and therapeutic interventions in collaboration with other professionals, if needed
- Provide verbal and written information about domestic violence and legal options
- Provide a listing of relevant community resources
- Make any necessary referrals
- Initiate mandatory reporting procedures when required
It is also critical to understand and implement the facility’s established safety protocols.
CARING FOR VICTIMS OF ABUSE
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.
Helping the Children
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:
- Learn about the cycle of violence and when violence is most likely to occur
- Recognize the clues that suggest the abuser is getting upset
- Watch for signs of drinking or drug abuse by the abuser
- Avoid behaviors that may worsen the abuser’s stress
- Avoid areas of the house where violence usually occurs
- Leave the house when domestic violence starts
- Stay with a friend or relative
A safety plan is something that an abuse victim can begin working on at any time. There are downloadable and printable forms available online, such as those available on 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:
- Where is the abuser now?
- Does the abuser know where the client is now?
- Has the abuser threatened to use weapons?
- Are weapons available to the abuser?
- Is the abuser intoxicated?
- Does the abuser have a criminal record?
- Are there children? Are they safe now?
- Are they being abused?
- Is the abuser verbally threatening the client?
- Is the abuser frightening relatives and friends?
Obtaining a Protective Order
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:
- Emergency protective order (EPO), which is an immediate temporary order
- Domestic violence order (DVO), which is a long-term order
In some states, a protective order will not be granted in cases where the victim and abuser are unmarried, do not live together, or do not have a child together.
CIVIL VERSUS CRIMINAL LAW
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).
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:
- Respect confidentiality
- Believe and validate experiences
- Acknowledge injustice
- Respect autonomy
- Help plan for future safety
Communities also benefit from advocacy activities. Healthcare professionals may be able to do one or more of the following:
- Provide professional or community education about family violence
- Participate actively to develop and maintain community resources for prevention of domestic violence
- Participate actively to develop and maintain community resources for intervention in domestic violence situations
- Participate on a Domestic Violence Coordinating Council
A MODEL PROTOCOL FOR ADDRESSING DOMESTIC VIOLENCE
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:
- Definitions: Include types of abuse and the persons who are covered by the protocol. Elder abuse and child abuse may be addressed separately.
- Principles: Include the institution’s philosophy about and commitment to addressing domestic violence.
- Identification and assessment procedures: Specify who is to do the assessment, screening tools and procedures, and how to ensure safety and confidentiality.
- Intervention procedures: Include interviewing strategies, safety assessment and planning, and discharge instructions. Addendums should address educational materials.
- State reporting requirements: Clarify the law. Include reporting procedures and forms as required. Define who is responsible for making the report.
- Confidentiality: Clarify privacy laws and ensure that the disclosure of health information serves to improve the health and safety of the victim.
- Collection of evidence and photographs: Include procedures for collection, storage, and release of evidence. Include procedures for taking photos and utilizing release forms.
- Medical record documentation: Clarify what information is to be included in the medical record.
- Referral and follow-up: Include instructions for resources, how to make referrals, domestic violence programs, and other community agencies. Update phone numbers regularly. Include instructions for victims to have at least one follow-up appointment.
- Staff education plan: Describe ongoing training for all staff.
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, healthcare professionals can identify, protect, and assist victims in resolving their situations.
To accomplish this goal, healthcare professionals 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:10.1891/1946-65220.127.116.11.
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
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.