Domestic Violence Education for Florida Nurses
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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
This course fulfills the Florida requirement for 2 hours of continuing education on domestic violence. We report to CE Broker.
Domestic Violence Education for Florida Nurses
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare Florida nurses to care for victims of domestic violence, with evidence-based information on its dynamics and effects on adult and child victims, legal remedies for protection, lethality and risk issues, available community resources and victim services, and reporting requirements.
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 types and dynamics of domestic violence.
- Recognize the signs and symptoms of domestic violence.
- Discuss appropriate documentation in cases of suspected domestic violence.
- State Florida’s reporting requirements for domestic violence.
- Describe actions to protect victims of domestic violence.
- Identify community resources and victim services for 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.
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 in Florida is defined as any assault, aggravated assault, battery or aggravated battery, sexual assault or battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member. Florida defines family or household member as current or former spouses, persons related by blood or marriage, persons who currently reside together or resided together in the past as if a family, parents of a child in common regardless of whether married or not. With the exception of those who have a child in common, the family or household members must currently reside or have in the past resided together in the same single dwelling unit (FL, 2014).
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. Domestic 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 victims do not report domestic violence to their physicians or to anyone else. However, the statistics available confirm that the problem is pervasive and alarming.
Victims of domestic violence are usually women and children. Recent national studies on domestic violence (DV) suggest that 22%–25% of all women will experience DV at some point in their lives and that many of these experiences will go unreported.
In Florida, statistics for 2013 indicate that:
- 108,030 domestic violence offenses were reported, leading to 65,645 arrests
- 170 domestically related murders were reported, with 105 perpetrators arrested
- 1,588 forcible rapes were reported, with only 578 arrests
- 85,606 simple assaults were reported, with a total of 51,333 arrests made
In Florida’s Orange County alone, the economic impact was found to be staggering. Domestic violence in 2010 cost county businesses $28 million in lost productivity, $62 million in medical expenses, and $31 million in mental health costs (HarborHouse, 2011).
Teens and Dating Violence
Teen dating violence is another form of DV 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 DV in adult relationships. Among adult victims of DV, 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).
DATING VIOLENCE AND FLORIDA LAW
Florida legislation defines dating violence as “violence between individuals who have or have had a continuing and significant relationship of a romantic or intimate nature.” The existence of such a relationship is determined based on the consideration of the following factors:
- A dating relationship must have existed within the past 6 months.
- The nature of the relationship must have been characterized by the expectation of affection or sexual involvement between the parties.
- The frequency and type of interaction between the persons involved in the relationship must have included that the persons have been involved over time and on a continuous basis during the course of a relationship.
The term does not include violence in a casual acquaintanceship or violence between individuals who only engaged in ordinary fraternization in a business or social context. It clarifies that those who are in a dating relationship are not required to have resided together to be eligible for an injunction for protection against violence.
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 physically or cognitively to 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 diverse 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 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. Similarly, some victims may not trust the police, fear deportation, feel shame or guilt, or have a history of child victimization.
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 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).
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).
Domestic 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 DV also have an increased risk of substance abuse, suicide, and risky sexual activity (SOGC, 2005).
Domestic violence often leads to chronic pain and/or depression. Although chronic pain and depression may have causes other than DV, either symptom should alert healthcare professionals to ask about DV, 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 DV (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 DV and persistent poverty intersect, they limit coping options. Both poverty and DV 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).
Poor 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 DV 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 DV (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.
Domestic violence 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 DV 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 DV than those without a disability. In fact, 37.3% of women with a disability reported experiencing some form of DV 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 DV. 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:
- 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
(KBN, 1997; NMJEC, 2005)
WHAT DOES DOMESTIC VIOLENCE LOOK LIKE?
Saltzman and colleagues (2002) identify four types of violence:
- Physical violence
- Sexual violence
- Threats of physical or sexual violence
- Psychological/emotional violence
Research indicates that domestic violence 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 DV and 1 in 5 of them reported pregnancy coercion and birth control sabotage. Both DV 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).
RAPE UNDER FLORIDA LAW
Florida Statute 794.011 currently includes rape under the offense of sexual battery. The statutes no longer give a separate legal definition for rape. The statute states the perpetrator must have engaged in oral, vaginal, or anal penetration of the victim with a sexual organ or another object or union by the perpetrator’s sexual organ with the victim’s mouth, vagina, or anus. If the rape victim is under the age of twelve, lack of consent is presumed, and if over the age of twelve, it must be shown the victim did not consent voluntarily. Under Florida laws, there needs to be shown a lack of consent but not a lack of resistance or protest.
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 UNDER FLORIDA LAW
Stalking is defined in Florida as willfully, maliciously, and repeatedly following, harassing, or cyberstalking another person. Stalking involves a pattern of unwanted behavior with malicious intent that causes substantial emotional distress to a specific person with no legitimate reason. Unwanted behavior can consist of many things such as actual following of a person or continuously calling, texting, e-mailing, leaving notes or sending letters, and leaving or sending objects or gifts.
Under Florida Statute 784.048, stalking is a first-degree misdemeanor charge. Aggravated stalking is a third-degree felony charge if the:
- Offender stalks a minor under the age of sixteen (16)
- Offender makes a credible threat of bodily injury or death
- Victim has an injunction for protection or other court-ordered prohibition of conduct by the offender
The explosion of digital technology—cellular phones, GPS systems, the Internet, and social networking websites 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)
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.
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.
At this point, she overcame her reluctance to seek help, and with the assistance of a DV counselor and the support of her family, left Anthony. She filed for divorce, obtained a protective order, and moved to an apartment with a strong security system in place.
Why Victims Stay
Both men and women can be victims of domestic violence, however most victims are women. 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
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. 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.
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.)
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 DV (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 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.
- Avoid phrases such as “patient claims” or “patient alleges” that cast doubt on the patient’s reliability. For example, use “Patient states she has abdominal pain” rather than “Patient alleges she has abdominal pain.”
- Avoid legal terms such as “alleged perpetrator” or “assailant.” Instead, use the name of the person who inflicted the injuries: “Patient states that Jack Smith, her ex-husband, struck her face with a closed fist.”
- Document objectively and report facts rather than using conclusive terms such as “assault and battery” or “domestic violence.”
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.
LEGAL REPORTING REQUIREMENTS IN FLORIDA
Although every person has a responsibility to report suspected abuse, neglect, or abandonment, some occupations are specified in Florida law as required to do so. These occupations are considered professionally mandated reporters, and their names are entered into the record of the report, but are held confidential.
Occupations Required to Report
- Assisted living facility staff
- Adult daycare center staff
- Adult family care home staff
- Bank, savings and loan, or credit union officer, trustee, or employee
- Chiropractor/chiropractic physician
- Day care center staff
- Department of Business and Professional Regulation staff conducting inspections of public lodging establishments
- Emergency medical technician
- Florida Advocacy Council member
- Foster care worker
- Hospital personnel engaged in the admission, examination, care, or treatment of children or vulnerable adults
- Health professional
- Institutional worker
- Law enforcement officer
- Long-term care ombudsman council member
- Medical examiner
- Mental health professional
- Nursing home staff
- Osteopath/osteopathic physician
- Practitioner who relies solely on spiritual means for healing
- Professional adult care, residential, or institutional staff
- Professional child care worker
- Residential care worker
- School teacher
- School official or other school personnel
- Social worker
- State, county, or municipal criminal justice employee or law enforcement officer
Content of Reports
The mandated person reporting abuse should be prepared to describe:
- Victim name(s)
- Possible responsible person or alleged perpetrator name(s)
- Complete address and/or directions to the location
- Telephone numbers, including area code
- Estimated or actual dates of birth
- Social Security numbers, if available
- A brief, concise description of abuse, neglect, abandonment, or exploitation, including physical, mental, or sexual injuries, if any
- Names of other residents and their relationship to the victim(s), if available
- A brief description of the victim’s disability or infirmity for vulnerable adults
- The relationship of the alleged perpetrator to the victim(s)
Where to Report Domestic Violence
One exception to the mandatory reporting of abuse concerns victims of domestic violence. In Florida, a healthcare provider may not report domestic violence without informed consent from an adult, even if the victim admits to the violence. Reporting suspected domestic violence without informed consent is considered unethical in the state of Florida and may leave the healthcare provider who reported the violence open to civil action.
The victim of domestic violence should be counseled to report the incident to law enforcement and be referred for guidance and support to a local Domestic Violence Advocacy organization. The Florida Domestic Violence Hotline number is 1-800-500-1119 (TTY 1-800-621-4202).
Florida Statue 790.24, however, does require healthcare professionals who knowingly treat a gunshot wound or life-threatening injury indicating an act of violence to report immediately to the county sheriff’s department, with or without the victim’s consent.
Where to Report Abuse of Children and Vulnerable Adults
Chapters 39 and 415 of the 2013 Florida Statutes (F.S.) state that any person who knows or has reasonable cause to suspect child abuse; neglect or abandonment by a parent, legal custodian, caregiver, or other responsible person; or abuse, neglect, and exploitation of vulnerable adults (including the elderly) who are unable to adequately provide for their own care or protection shall immediately report such knowledge or suspicion to the Florida Abuse Hotline of the Department of Children and Families:
- Phone: 1-800-96ABUSE (2-2873)
- TDD: 1-800-453-5145
- Fax: 1-800-914-0004
- Website: reportabuse.dcf.state.fl.us
Donna, an office nurse in a busy OB/GYN practice in Florida, 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 admitted they were the result of her husband kicking her. Following Florida protocol, Donna counseled Brandy to report the incident to law enforcement, especially because of the possibility of harm to her unborn baby. However, Brandy did not want to do so and expressed fear of what would happen if Donna reported the abuse herself.
Donna told her that she could not report domestic violence without Brandy’s consent, but that she was required to recommend she contact law enforcement and refer her for guidance and support to the local Domestic Violence Advocacy organization. Donna gave Brandy the Florida Domestic Violence Hotline number and encouraged her to call.
DOMESTIC VIOLENCE AND DEMENTIA
Often law enforcement is called for a domestic disturbance to the homes of elderly persons, and police often don’t recognize that the aggressor has dementia. Even if they do, police often make an arrest in order to comply with domestic violence laws.
In Florida the legal system has struggled with domestic violence and dementia issues. These issues are becoming more common as the number of seniors, and those with dementia, rises. These persons are increasingly becoming involved with law enforcement, causing police, prosecutors, judges, psychiatric workers, and other caregivers to struggle to find a balance between humane treatment of this vulnerable but sometimes aggressive segment of the population and the need to protect the public.
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.
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. While in court for the hearing, Ms. Rosa asked if her husband was present (Hefler, 2013).
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. The Florida Coalition Against Domestic Violence creates and distributes safety planning tools to all Florida’s certified Domestic Violence Centers in multiple languages and addressing many culturally specific issues. Domestic violence victims wishing to create a safety plan can do so by calling the Florida Domestic Violence Hotline (1-800-500-1192) and working with a domestic violence or dating violence advocate.
Nurses and other healthcare professionals should have on hand information about accessing a safety plan as well as 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 the children also being abused?
- Is the abuser verbally threatening the client?
- Is the abuser frightening relatives and friends?
Obtaining an Injunction
A protective order or injunction for protection 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 Florida:
- Temporary (ex parte) injunctions designed to provide immediate protection
- Final injunction, which may set a period of time or may not have an expiration date
Aside from an injunction for protection against domestic violence, there are three other types of injunctions available in Florida:
- Injunction against repeat violence (which includes stalking)
- Injunction against dating violence
- Injunction against sexual violence
CIVIL VERSUS CRIMINAL LAW
In Florida, injunctions for protection 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).
COMMUNITY RESOURCES AND PREVENTION
Domestic Violence Services in Florida
The Domestic Violence Program works closely with the Florida Coalition Against Domestic Violence to regulate, certify, and monitor the 42 domestic violence centers across the state of Florida. These domestic violence centers provide crisis intervention and support services to adult victims of domestic violence and their children free of charge, 24 hours a day, 7 days a week.
The Florida Coalition Against Domestic Violence’s Economic Justice Initiative (FCADV, 2014) is meant to assist those working with domestic violence survivors to provide economic empowerment programs. These programs provide education in financial literacy, access to local resources, expanding access to banking services, and building financial stability. In addition, FCADV provides assistance to identify potential solutions to long-term housing needs. It is reported that there are emergency shelters for those survivors in immediate danger, but there are no affordable housing options available that provide long-term housing (Wick & Douglass, 2014).
Most communities also have Child Protective Services and Adult Protective Services agencies to which known or suspected cases of abuse should be reported.
Florida law has established batterers intervention programs for perpetrators of domestic violence. Attendance at a batterer’s intervention program is usually imposed by the court as a condition of probation. According to the Florida Department of Law Enforcement (2010), 75% of those who perpetrate domestic violence are male, and therefore its efforts at certification of and setting standards for these programs has focused on programs designed for men who commit acts of domestic violence.
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
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, 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. Nurses must put forth a coordinated effort with advocacy groups, community resources, and law enforcement in order to be effective change agents.
Dating Matters (CDC) (60-minute interactive training on teen dating violence)
Florida Department of Children and Families Abuse Hotline
1-800-96-ABUSE (1-800-962-2873); TDD 1-800-453-5145; Fax 1-800-914-0004
Florida Domestic Violence Hotline
1-800-500-1119; TTY: 1-800-621-4202
Florida Elder Helpline
1-800-955-8771; TDD: 1-800-955-8770
National Domestic Violence Hotline
800-799-SAFE (7233); TTY: 800-787-3224
Rape, Abuse, and Incest National Network (RAINN)
Spouse Abuse Shelter Hotline
Violence Prevention (CDC)
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