According to the CDC's 2010 National Intimate Partner and Sexual Violence Survey, more than 1 in 3 women (35.6%) and more than 1 in 4 men (28.5%) in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Because of the number of individuals affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims. Accordingly, it is essential that healthcare professionals are taught to recognize and accurately interpret behaviors associated with domestic violence. It is incumbent upon the healthcare professional to establish and implement protocols for early identification of domestic violence victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, healthcare professionals in all settings must take the initiative to properly assess all patients for abuse during each visit and, for those who are or may be victims, to offer education, counseling, and referral information.
This course is designed for all Kentucky healthcare professionals who may intervene to protect victims of domestic violence.
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This course fulfills the Kentucky requirement for 3 hours of Domestic Violence Education. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.
The purpose of this course is to enable Kentucky healthcare professionals in all practice settings to define domestic violence and identify those who are affected by domestic violence. This course describes how a victim can be accurately diagnosed and identifies resources available for domestic violence victims.
Upon completion of this course, you should be able to:
- Define domestic violence.
- Recognize the characteristics and dynamics experienced by those groups who are risk for domestic violence, including pregnant women, children, men, and same-sex couples.
- Describe how to screen for patients who have a history of being a victim or perpetrator of domestic violence, including aspects of a culturally sensitive assessment.
- Outline interventions targeted to victims of domestic violence.
- Review resources available for domestic violence victims.
Marjorie Conner Allen, BSN, JD, received her Bachelor of Science in Nursing degree from the University of Florida, Gainesville, in 1984. She began her nursing career at Shands Teaching Hospital and Clinics at the University of Florida, Gainesville. While practicing nursing at Shands, she gave continuing education seminars regarding the nursing implications for dealing with adolescents with terminal illness. In 1988, Ms. Allen moved to Atlanta, Georgia where she worked at Egleston Children’s Hospital at Emory University in the bone marrow transplant unit. In the fall of 1989, she began law school at Florida State University. After graduating from law school in 1992, Ms. Allen took a two-year job as law clerk to the Honorable William Terrell Hodges, United States District Judge for the Middle District of Florida. After completing her clerkship, Ms. Allen began her employment with the law firm of Smith, Hulsey & Busey in Jacksonville, Florida where she has worked in the litigation department defending hospitals and nurses in medical malpractice actions. Ms. Allen resides in Jacksonville and is currently in-house counsel to the Mayo Clinic Jacksonville.
Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.
Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.
Dee Spring, PhD, MFT, ATR-BC, an international lecturer, specializes in the treatment of individuals who experienced "intimate" trauma with resultant PTSD; she is a consultant and qualified expert witness in several states. She has written professional articles, book chapters, and authored two books. Dr. Spring has taught at many universities and conducted training for professionals in a variety of settings. Additionally, she designed, implemented and directed the first federally funded rape crisis center in the world to utilize visual art in crisis intervention and treatment for victims of sexual assault. She is Past President of the California Society for the Study of Trauma and Dissociation and a past member of the Board of Directors of the American Art Therapy Association, receiving awards from both for clinical and educational achievements, contributions, and innovations related to research and use of visual art in trauma treatment. Regrettably, Dr. Spring passed away in 2010.
Contributing faculty, Marjorie Conner Allen, BSN, JD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Contributing faculty, Dee Spring, PhD, MFT, ATR-BC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Ronald Runciman, MD
Jane C. Norman, RN, MSN, CNE, PhD
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
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#97911: Domestic Violence: The Kentucky Requirement
Domestic violence continues to be a prevalent problem in the United States. Because of the number of individuals affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims. Accordingly, it is essential that healthcare professionals are taught to recognize and accurately interpret behaviors associated with domestic violence. It is incumbent upon the healthcare professional to establish and implement protocols for early identification of domestic violence victims and their abusers. In order to prevent domestic violence and promote the well-being of their patients, healthcare professionals in all settings must take the initiative to properly assess all patients for abuse during each visit and, for those who are or may be victims, to offer education, counseling, and referral information.
Victims of domestic violence suffer emotional, psychological, and physical abuse, all of which can result in both acute and chronic signs and symptoms. Victims may present with physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims encounter and are in a critical position to identify domestic violence victims in a variety of clinical practice settings where victims receive care. Healthcare professionals must educate themselves to enhance awareness of domestic violence in each particular practice or clinical setting.
Domestic violence, termed spousal abuse, battering, or intimate partner violence (IPV), refers to the victimization of an individual with whom the abuser has or has had an intimate or romantic relationship. The Centers for Disease Control and Prevention (CDC) define IPV as, "violence committed by a spouse, ex-spouse, or current or former boyfriend or girlfriend. It occurs among both heterosexual and same-sex couples and is often a repeated offense" . Domestic violence can consist of any of many behaviors or combination of behaviors, falling under physical, psychological, verbal, sexual, and financial/economic abuse (Table 1).
DOMESTIC VIOLENCE BEHAVIORS
|Physical Abuse||Psychological/Verbal Abuse||Sexual Abuse||Financial/Economic Abuse|
|Kicking, punching, biting, slapping, strangling, choking, abandoning in unsafe places, burning with cigarettes, throwing acid, throwing objects, refusing to help when sick, stabbing, shooting||Intimidation, humiliation, put-downs, ridiculing, control of victim's movement, stalking, threats, threatening to hurt victim's family and children, social isolation, ignoring needs or complaints||Rape, forms of sexual assault (such as forced masturbation, fellatio, or oral coitus), sexual humiliation, perpetrator refuses to use contraceptives, coerced abortion||Withholding of money, refuse to allow victim to open bank account, all property is in the perpetrator's name, victim is not allowed to work|
The state of Kentucky has formulated the following definitions :
"Domestic violence and abuse" refers to physical injury, serious physical injury, stalking, sexual abuse, assault, or the infliction of fear of imminent physical injury, serious physical injury, sexual abuse, or assault between family members or members of an unmarried couple.
"Family member" is defined as a spouse (including a former spouse), a grandparent, a grandchild, a parent, a child, a stepchild, or any other person living in the same household as a child if the child is the alleged victim.
"Member of an unmarried couple" is used to describe each member of an unmarried couple that allegedly has a child in common, any children of that couple, or a member of an unmarried couple who are living together or have formerly lived together.
These are legal definitions utilized by the courts to determine under which circumstances an individual should be prosecuted for domestic violence.
It is important for healthcare professionals to understand that domestic violence, in the form of emotional and psychological abuse and physical violence, is prevalent in society. Unfortunately, domestic violence and abuse has become a fact of life for many Americans. This course will use the terms "domestic violence" and "IPV" interchangeably.
Since the 1970s, domestic violence has emerged as one of the most serious public health problems facing women in this country . According to the CDC's 2010 National Intimate Partner and Sexual Violence Survey, more than 1 in 3 women (35.6%) and more than 1 in 4 men (28.5%) in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime . Although many of these incidents consist of pushing, grabbing, shoving, slapping, and hitting, 2 million injuries and 2,340 deaths from IPV occur nationwide every year [1,4,5].
According to the Kentucky Cabinet for Health and Family Services, women in Kentucky are more likely to experience IPV than the national average . As of 2006, more than one-third (36.6%) of women in Kentucky reported having been the victim of IPV. It is also estimated that one in nine women in Kentucky will be the victim of sexual assault in their lifetime . In the United States, it is estimated that 30% of all female murder victims and 5% of male victims are killed by intimate partners . One study of firearm homicide followed by suicide in Kentucky determined that in 80% of cases, the victim and perpetrator were family members or intimates . This demonstrates that domestic violence, and its associated consequences, is a real threat to the residents of Kentucky. As a result of these troubling statistics, the Kentucky Legislature enacted legislation that requires all mental health professionals, physicians, and nurses who have been granted licensure or certification after July 15, 1996 to complete a 3-hour continuing education course on domestic violence .
Victims of abuse often suffer severe physical injuries and will likely seek care at a hospital or clinic. The health and economic consequences of domestic violence are significant, although statistics vary from report to report. One of the difficulties in addressing the problem is that abuse cannot be predicted by any demographic feature related to age, ethnicity, race, religious denomination, education, or socioeconomic status or class.
In 2003, the CDC published the results of its U.S. Congress-funded study to determine the cost of domestic violence on the healthcare system . The CDC report, which relied on data from the National Violence Against Women Survey conducted in 1995, estimated the costs of IPV by measuring how many female victims were nonfatally injured; how many women used medical and mental healthcare services; and how many women lost time from paid work and household chores in 1995. The estimated total cost of IPV against women in 1995 was more than $5.8 billion; when updated to 2003 dollars, the cost is more than $8.3 billion. It must be noted that the costs of any one victimization may continue for years; therefore, these numbers most likely underestimate the actual cost of IPV [1,10]. No other major analyses of the costs of IPV have been conducted since 2003.
The rate of serious domestic violence against women has declined significantly from 1994 to 2011, from 5.9 victimizations per 1,000 females 12 years of age or older in 1994 to 1.6 per 1,000 in 2011 . The rate of overall family violence also fell by more than one-half in this time period [11,12]. Studies reveal that several factors may be contributing to the reduction in violence, including a decline in the marriage rate and a decrease of domesticity, better access to federally funded domestic violence shelters, improvements in women's economic status, and demographic trends, such as the aging of the population [13,14].
Healthcare professionals are in a critical position to identify domestic violence victims in a variety of clinical practice settings in which women receive care. Nurses are often the first healthcare provider a victim of domestic violence will encounter in a healthcare setting, and must therefore, be prepared to provide care and support for these victims. Although women are most often the victims of violence, domestic violence extends to others in the household as well. For example, domestic violence occurs when children are abused by their parents, when parents are abused by their children, when elderly are abused, and when siblings abuse each other.
Because a gynecologist or obstetrician is frequently a woman's primary care physician, these healthcare providers should be particularly sensitive to domestic violence issues . According to the CDC, IPV affects as many as 324,000 pregnant women each year . This represents approximately 8% of all pregnant women in the United States. As with all domestic violence statistics, this number is presumed to be lower than the actual incidence as a result of under-reporting and lack of data on women whose pregnancies ended in fetal or maternal death. This makes IPV more prevalent among pregnant women than some of the health conditions included in prenatal screenings, including pre-eclampsia and gestational diabetes . Because 96% of pregnant women receive prenatal care, this is an optimal time to screen for domestic violence and develop trusting relationships with the women. Possible factors that may predispose pregnant women to IPV include young maternal age, unintended pregnancy, delayed prenatal care, lack of social support, and use of tobacco, alcohol, or illegal drugs [16,17].
The overarching problem of violence against women cannot be ignored, especially as both mother and unborn child are at risk. At this particularly vulnerable time in a woman's life, an organized clinical construct leading to immediate diagnosis and medical intervention will ensure that therapeutic opportunities are available to the pregnant woman and will reduce the potential negative outcomes [18,19]. Healthcare professionals should also be aware of the possible psychological consequences of abuse during pregnancy. There is a higher risk of stress, depression, and addiction to alcohol and drugs in abused women, and victims are less likely to obtain prenatal care .
The United States is becoming increasingly diverse in terms of ethnic composition. According to the 2010 Census, 308.7 million people resided in the United States on April 1, 2010—an increase of 27.3 million people, or 9.7%, between 2000 and 2010, with the vast majority due to increases in racial/ethnic minority populations .It is inevitable, therefore, that race, culture, and ethnicity will have a profound effect on American culture. Consequently, health professionals must become more aware of, and sensitive to, the cultural norms, belief systems, and needs of culturally diverse patients in order to provide relevant services and interventions. Results from the National Violence Against Women Survey indicate that all racial minorities in the United States experience more IPV than white Americans, with the exception of Asian Americans [12,22]. It has been suggested that ethnic minority groups may be more vulnerable to violence as a result of environmental risk factors such as poverty, racism, oppression, and discrimination. For example, one study suggests that nearly one-third of African American women experience IPV in their lifetimes, compared with one-fourth of white American women . Another study with 1,155 Mexican American women found that 10.7% of the sample reported physical abuse by a current partner. Researchers found that those born in the United States reported a rate of violence higher than those born in Mexico . In the Asian American community, the mistaken notion that Asian Americans have achieved success often cloaks the issue of domestic violence. In a telephone interview with 336 Asian American women in the San Francisco and Los Angeles areas, 27% experienced emotional abuse by an intimate partner, 16% reported being pressured to have sex without their consent, and 12% reported that an intimate partner had hurt or had attempted to hurt them by means of hitting, kicking, slapping, shoving, object throwing, or threatening their lives with a weapon . Although this is a small study, it does indicate that domestic abuse is an issue for some Asian Americans.
Culture, race, and ethnicity also influence help-seeking patterns. Help-seeking behavior is in part influenced by an individual's definition and understanding of abuse, which is ultimately influenced by culture. For example, an ethnic minority woman who is being abused by her husband may not seek help if she does not label the event as a problem. Instead, she may believe the abuse is something to be persevered. Financial limitations, suspiciousness or wariness of health or mental health professionals, limited English proficiency, and inconvenience in locating and traveling to agencies are also hindrances specific to these populations .
Children who are raised in violent homes are also in danger. These children are at high risk for abuse and for emotional damage that may affect them as they grow older. Slightly more than half of female victims of domestic violence live in a household with at least one child younger than 12 years of age, and between 3.3 million and 10 million children witness domestic violence annually [24,26]. Studies demonstrate that children who witness domestic violence are more likely to grow into a perpetrator or victim of domestic violence than a child who was himself or herself abused, thereby creating a cycle of violence. For example, in one study, adolescent witnesses of abuse were also more likely to report having perpetrated abuse (42%) compared to non-witnesses (15%) . Research regarding the psychosocial outcomes of children exposed to domestic violence has found that child witnesses exhibit more aggression, anxiety, difficulties with peers, and academic problems than the average child [26,28]. An estimated 47% of children who have witnessed IPV at home are younger than 6 years of age, and these preschool-age children are more likely to show evidence of internalizing behavior problems (e.g., anxiety, depression, somatic complaints) compared to older children, who show more signs of externalizing behavior problems (e.g., bullying, aggression, misconduct) . In addition to witnessing violence, these children may also become direct victims of violence, as child maltreatment occurs in 30% to 60% of families in which IPV is reported . Moreover, statistics demonstrate that 85% of domestic violence victims abuse or neglect their children.
Adolescents are also victimized. According to the U.S. Department of Justice, 17.5% of all homicides against girls 12 to 17 years of age are committed by an intimate partner . Among young women 18 to 24 years of age, the rate is 42.9%. Abused teens often do not report the abuse. Individuals 12 to 19 years of age report only 35.7% of crimes against them, compared to 54% in older age groups . Accordingly, healthcare professionals who see young children and adolescents in their practice must have the tools necessary to detect these "silent victims" of domestic violence and to intervene quickly to protect young children and adolescents from further abuse.
Abused and neglected elders, who may be mistreated by their spouses, partners, children, and other relatives, are among the most isolated of all victims of family violence. In a national study conducted by the National Center on Elder Abuse, there was a total of 565,747 reports of elder abuse to Adult Protective Services in the United States in 2004, 461,135 of which were investigated. This was a nearly 200% increase from the 293,000 reports in 1996 . The vast majority (90%) of perpetrators are family members .
Because elder abuse can occur in family homes, nursing homes, board and care facilities, and even medical facilities, healthcare professionals must remain keenly aware of the potential for abuse. When abuse occurs between elder partners, it is primarily manifested in one of two ways, either as a long-standing pattern of marital violence, or as abuse originating in old age. In the latter case, abuse may be precipitated by issues related to advanced age, including the stress that accompanies disability and changing family relationships.
It is important to understand that the domestic violence dynamic involves not only a victim but a perpetrator as well. For example, an adult son or daughter who lives in the parents' home and depends on the parents for financial support may be in a position to inflict abuse. This abuse may not always manifest itself as violence, but can lead to an environment in which the elder parent is controlled and isolated. The elder may be hesitant to seek help because the abuser's absence from the home may leave the elder without a caregiver. Because these elderly victims are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected. Healthcare professionals in all settings must remain aware of the potential for abuse and keep a watchful eye on this particularly vulnerable group.
Statistics confirm that domestic violence is predominantly perpetrated by men against women; however, there is evidence to suggest that women also exhibit violent behavior against their male partners . Studies demonstrate that approximately 5% of murdered men are killed by intimate partners . It is persuasively argued that the impact on the health of female victims of domestic violence is generally much more severe than the impact on the health of male victims . However, approximately 7% men are raped and/or physically assaulted by an intimate partner in their lifetime . In 2008, men experienced 101,000 nonfatal violent victimizations by an intimate partner . Healthcare professionals should always keep in mind that men can also be victimized.
Domestic violence exists in the gay, lesbian, and bisexual community, with the 2010 National Intimate Partner and Sexual Violence Survey indicating that 43.8% of lesbian women, 61.1% of bisexual women, 26% of gay men, and 37.3% of bisexual men reporting ever having experienced rape, physical violence, and/or stalking by an intimate partner . Men living with male intimate partners experience significantly more IPV than men who live with female intimate partners . This supports other statistics indicating that IPV is perpetrated primarily by men. Because of the stigma of being gay, victims may be reticent to report abuse and afraid that their sexual orientation will be revealed. Many in this community feel that support services are not available to them due to prejudices of the service providers. Unfortunately, this results in the victim feeling isolated and unsupported. Healthcare professionals should strive to be sensitive and supportive when working with homosexual patients.
As with domestic violence in the civilian population, military victims face a host of barriers in disclosing abuse. In addition to shame and embarrassment, fear of reprisals, feelings of isolation, and lack of available services, many military victims found when they did report abuse, military personnel were not sensitive to their needs . Given these barriers to disclosure, it is difficult to assess the prevalence of domestic violence among military families. According to the U.S. Department of Defense, there were a total of 18,208 reported incidents of domestic abuse in 2009 . However, it should be noted that a 2010 report released by the U.S. General Accounting Office (GAO) indicated that the U.S. Department of Defense's use of multiple registries and inclusion of only those reports made to the Family Advocacy Program (excluding cases handled by civilian law enforcement, identified by nonmilitary medical staff, and reported to commanders) make calculating the actual number of domestic violence cases impossible .
The Family Advocacy Program is responsible for seeing that victims remain safe and have access to support and advocacy services and that offenders receive appropriate intervention services . The Program works to prevent domestic abuse by educating service members and families about the issue; identifying families experiencing domestic abuse; providing support services to victims of abuse; and providing treatment for abusers.
Risk factors among this group are complex and multifaceted. Brewster conducted a study of 2,991 abusers who used physical domestic violence that received treatment at the Air Force Family Advocacy Program and agreed to participate in the study. As with the general population, the physical violence sustained was more severe when the offender was male. However, previously reported domestic violence cases were higher than the base rate for the general population—one in four had been reported for spouse abuse, and one in eight offenders had been substantiated for spouse abuse .
It has also been speculated that deployment, exposure to the trauma of combat, and the development of post-traumatic stress symptoms provokes military veterans to be violent at home [43,44]. Furthermore, when these veterans do obtain treatment, either voluntarily or as mandated, many do not complete their treatment regimens.
A tremendous barrier to diagnosing and treating domestic violence is a lack of knowledge and training. Healthcare workers are generally able to recognize and accurately interpret behaviors associated with domestic violence and abuse; however, they are often hesitant to inquire about abuse [45,46]. In a nationally representative sample, only 7% of women reported ever being asked about domestic violence or family violence by a healthcare professional . One meta-analysis analyzed IPV screening rates from 1992 to 2005, finding that 3% to 41% of physicians reported routine screening; physicians caring for pregnant patients reported routine screening 11% to 39% of the time .
Although the American Medical Association, the American College of Obstetricians and Gynecologists, the American Nurses Association, and the U.S. Preventive Services Task Force all recommend screening women for IPV at each patient contact, this practice is not being incorporated into routine clinical practice . Several barriers to incorporating domestic violence screening have been identified, including lack of physical evidence of abuse, perceptions regarding prevalence of abuse, lack of training and continuing education on the topic, and lack of office protocols [48,50]. To help address the lack of adherence to screening guidelines, the U.S. Department of Health and Human Services included screening and counseling for interpersonal and domestic violence in women's preventive health care that must generally must be covered by health plans with no cost sharing in the 2010 Affordable Care Act .
It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims. These guidelines should review appropriate interview techniques and should also include the utilization of screening tools, such as intake questionnaires. The following is a review of certain signs and symptoms that may indicate the presence of abuse. Although victims of domestic violence do not display typical signs and symptoms when they present to healthcare providers, there are certain cues that may be attributable to abuse. The obvious cues are the physical ones. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen. These are often distinguishable from accidental injuries, which are more likely to involve the periphery of the body. In one hospital-based study, domestic violence victims were 13 times more likely to sustain injury to breast, chest, or abdomen than accident victims. Abuse victims are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen in a patient, particularly in combination with evidence of old injury, physical abuse should be suspected .
In addition to physical signs and symptoms, domestic violence victims also exhibit psychological cues that resemble an agitated depression. As a result of prolonged stress, victims often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches, and digestive problems. Often they will complain of fatigue, restlessness, insomnia, or loss of appetite. Great amounts of anxiety, guilt, and depression or dysphoria are also typical [19,52]. In many women, this constellation of symptoms has been labeled "Battered Women's Syndrome." Unfortunately, physicians may respond to these women by diagnosing the patient to be neurotic or irrational . Healthcare professionals must cast aside these misperceptions of abused victims and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms.
For every victim of abuse, there is also a perpetrator. Like their victims, perpetrators of domestic violence come from all socioeconomic backgrounds, races, religions, and walks of life . Accordingly, healthcare professionals must be aware that seemingly supportive family members may, in fact, be abusers. Perpetrators and their victims in lower socioeconomic groups are more likely to present in hospital emergency rooms and local community clinics. Conversely, people of higher socioeconomic status are more able to turn to the private clinician for assistance .
Abuser characteristics have been studied far less frequently than victim characteristics. Some studies suggest a correlation between the occurrence of abuse and the consumption of alcohol. A man who abuses alcohol is also likely to abuse his mate, although the abuser may not necessarily be inebriated at the time the abuse is inflicted . Screening questionnaires should include questions that explore social drinking habits of both the victim and his or her mate.
Other studies demonstrate that abusive mates are generally possessive and jealous. Another characteristic related to the batterer's dependency and jealousy is extreme suspiciousness. This characteristic may be so extreme as to border on paranoia . In addition, domestic violence victims have frequently reported that abusers are extremely controlling of the everyday activities of the family. This domination is generally all encompassing. One battered woman gave the following examples of her controlling husband: "He insisted that no one (including guests and their toddler children) wear shoes in the house, that the furniture be in the same indentations in the carpet, that the vacuum marks in the carpet be parallel, and that any sand that spilled from the children's sandbox during their play be removed from the surrounding grass" . In addition, healthcare professionals should be on the lookout for men who have low self-esteem, are frequently angry and depressed, and are "very dependent on their partners as the sole source of love, support, intimacy, and problem solving" .
Both batterers and battered partners are noted for being extremely dependent upon each other. It appears that each member of the couple believes that he or she will perish without the other and that the survival of each can only occur if the conjugal relationship remains intact. This belief ostensibly arises from their negative self images, which cause the couple to doubt both their ability to live independently and to find other partners who will accept them. Both tend to deny or minimize the scope and severity of the violence in their relationship. This denial makes the conjugal relationship appear more viable and desirable to both .
These particular relationship dynamics are not easily detected under the best of circumstances. They may be especially difficult to uncover in circumstances in which the parties are suspicious and frightened, as might be expected when a victim presents to an emergency room. The key to detection, however, is to establish a proper screening tool that can be utilized in the particular setting, and to maintain a keen awareness for cues. Screening should be carried out at the entry points of contact between victims and medical care (e.g., primary care, emergency services, obstetric and gynecologic services, psychiatric services, pediatric care) .
An initial screening should focus on obtaining an adequate history. Establishing that a patient's injuries are secondary to battering is the first task. Clearly there will be times when a victim is injured so severely that treatment of these injuries becomes the first priority . After such treatment is rendered, however, it is important that healthcare professionals not ignore the reasons that brought the victim to the emergency room.
Of female trauma patients, 16% to 30% will report that they have been battered when asked directly about how the injury occurred. Obviously, however, some victims will not admit to a history of battering. Any trauma or burn that seems incompatible with a history of the injury is suggestive of battering and indicative of the need for gentle probing regarding how things are at home. Information must also be collected to facilitate a comprehensive assessment of the victim's needs, resources, and priorities in order to develop immediate and long-range plans designed to minimize and eliminate future abusive episodes. A structured interview can be used to obtain the necessary information for treatment planning (Table 2) .
STRUCTURED INTERVIEW FOR TREATMENT PLANNING
After the history is obtained and initial treatment is started, it is imperative to document all findings and recommendations in the victim's medical record. The medical record can be invaluable in establishing the credibility of the domestic violence victim's story when he or she seeks legal aid .
Healthcare professionals must be aware of their legal obligation to report domestic violence to the proper authorities. Kentucky law requires healthcare professionals to report cases of suspected spouse abuse to the Cabinet for Health and Family Services when they determine that a patient is the victim of abuse or neglect inflicted by a spouse [58,59,60]. This particular law does not encompass domestic violence generally, but only cases in which the abuse is committed by a spouse. Practically speaking, this leads healthcare providers to make a series of decisions. When providers become aware of an abuse situation, they must determine who is inflicting the abuse. If it is determined that a spouse is abusing the patient, then the obligation to report is mandatory. Another provision of Kentucky law encompasses other types of domestic violence. If healthcare professionals are unable to determine who has inflicted abuse on a patient, either because the patient refuses or is unable to tell, they must then determine if the victim, because of mental or physical dysfunctioning, is able to manage his or her own resources and carry out the activities of daily living. In addition, healthcare professionals must ascertain whether or not the patient can protect himself or herself from neglect or hazardous or abusive situations without assistance from others. If the answer to either question is no and the patient is in need of protective services, then again, the obligation to report is mandatory [59,60].
A physician may argue that reporting abuse without the patient's consent would be a violation of the physician-patient relationship. The law mandating healthcare professionals to report instances of spousal abuse is, however, a legislative exception to the physician-patient confidentiality rule . If a healthcare professional knowingly and willfully fails to report a case of suspected abuse as mandated by the law, then he or she can be subject to criminal penalties . In fact, a healthcare professional who reports a suspected case of abuse in good faith in accordance with these laws is protected from civil and criminal liability .
During the assessment process, a practitioner must be open and sensitive to the client's/patient's worldview, cultural belief systems, and how he/she views the injury . This may reduce the tendency to over-pathologize or minimize health concerns of ethnic minority patients. Pachter proposed a dynamic model that involves several tiers and transactions . The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. Professionals must be willing to acknowledge that they do not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups they come in contact with. Reading and becoming familiar with medical anthropology is a good first step.
The second component emphasizes the need for specifically tailored assessment . Pachter advocates the notion that there is tremendous diversity within groups. For example, one cannot automatically assume that a Chinese immigrant adheres to traditional beliefs. Often, there are many variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the client/patient and the professional . The negotiation consists of a dialogue that involves a genuine respect of beliefs. It is important to remember that these beliefs may affect symptoms or appropriate interventions in the case of domestic violence.
Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. These components are meant to provide an introduction to help practitioners recognize the range of dimensions, including physical, biological, social, and cultural factors, that affect immigrants and ethnic minorities. By incorporating cultural sensitivity into the assessment of individuals with a history of being victims or perpetrators of domestic violence, it may be possible to intervene and offer treatment more effectively.
All practitioners who deal with domestic violence should periodically review safety planning with victims. Homicide is of high risk for victims; therefore, safety planning is crucial. When advocating a safety plan, it is important to:
Encourage the victim to be aware of weapons in the residence.
Have victims make a plan of what to do if violence escalates and where to go if leaving is an option.
If children are old enough, they should be instructed about the safety plan and assigned roles.
When possible, victims should save some money in a private bank account or hide money for escape. Victims should be informed that if the abuser finds out about a separate bank account, they could be in danger.
Encourage victims to keep a bag packed with necessities and stored in a safe place in the event leaving must be immediate.
Advise victims to work out a code word or signal with the children so they will know when to implement an escape plan.
Encourage victims to keep a list of important phone numbers in their packed bag. Memorizing important numbers provides more safety.
Recommend that copies of important documents and necessary items be available.
Although safety planning may be advocated, it does not necessarily mean victims will employ safety planning guidelines.
If a victim requires or requests legal assistance, local spousal abuse centers will be able to assist in making the appropriate referral. For the purposes of this course, it is important for healthcare professionals to know that domestic violence victims in Kentucky have legal remedies available to them.
The first form of legal protection is an emergency protective order, which can be filed and heard by a judge without the batterer being informed of the filing or of the hearing. The batterer will not be present at the hearing, and the victim can present his or her evidence unopposed. This is referred to in the legal community as an ex parte hearing. The associated forms are relatively simple to file, and an attorney is not required. Having an attorney present, however, may result in obtaining a more thorough order. If the victim is not represented by an attorney, it is important that a battered woman's advocate, often called a legal advocate, be located to accompany the victim to court. To find an advocate trained in domestic violence issues, healthcare professionals may contact a local domestic violence center. The most ideal representation and assistance in these circumstances is usually a team approach that draws upon the expertise of an attorney and a domestic violence advocate/counselor .
Kentucky law provides that a judge can enter an emergency protective order or a domestic violence order that :
Restrains the batterer from any contact or communication with the abused party, except as directed by the court
Restrains the batterer from committing further acts of domestic violence and abuse
Restrains the batterer from disposing of or damaging any of the property of the parties
Directs the batterer to vacate the residence shared by the abused party
Grants temporary custody of minor children under certain circumstances
Restrains the batterer from coming within a certain distance of specifically described locations or persons
The judge is not restricted to only these remedies, but can enter other orders he or she believes will be of assistance in eliminating future acts of domestic violence and abuse. The emergency protective order will be effective for a fixed period of time, as noted in the order, not to exceed 14 days. A copy of this order will be served upon the batterer, and if he or she violates any condition of the order, criminal penalties may be levied .
The court reviews petitions for protective orders on filing and schedules an evidentiary hearing with 14 days, at which the batterer is given notice of the hearing and is allowed to attend and present witnesses. If the court finds that a protective order is warranted, a domestic violence order will be followed to restrain the batterer from having contact with the victim . In a domestic violence order, the protection is effective for up to three years, at which time it can be reissued. Batterers who violate the conditions of the protective order are subject to criminal penalties, including incarceration.
If a batterer violates the terms of the protective order, the police should be contacted immediately. When the police arrive, the victim should show the police the order or inform the officers of its existence. In Kentucky, a police officer who witnesses the batterer violating the terms of the protective order is required to arrest him or her . If the batterer is no longer present when the police arrive, the victim should request that a report of the violation, and of any other crimes, be written. The victim can then follow-up on the violation by contacting the prosecutor's office and ask that an arrest warrant be issued based on the violation .
If an arrest is made for a misdemeanor, such as violating a protection order, offenders may simply be given a citation and released. If a batterer is arrested and taken into custody, he or she may be released within a few hours. It is important, therefore, to advise victims to use this time to gather their children and personal belongings, to find a safe place to stay, to begin the process of obtaining a protection order if they do not have one, and/or to seek out a domestic violence program . Victims should be fully informed about the criminal justice process, their role in it, and the possible outcomes of a criminal case so they can decide whether to turn to the criminal justice system for assistance.
If the prosecuting attorney decides to pursue a criminal complaint, there will be an arraignment. During the arraignment, the court informs the batterer of the charges and ensures that he or she has legal representation. Victims may be called to testify at an evidentiary hearing or at trial. If a victim does not want to testify, a court may issue a subpoena ordering him or her to testify; noncompliance with such a subpoena is a violation of law. Most cases are resolved before trial; if the case proceeds to trial, however, victims are again required to testify . If the batterer is convicted, a judge will sentence him or her to one or any combination of the following: a fine; imprisonment; probation; victim restitution; mandatory counseling; mediation; substance-abuse treatment; or public service .
After identifying victims and their abusers, healthcare professionals should immediately implement a plan of action that includes providing a referral to a local domestic violence shelter to assist the victim and the victim's family. The acute situation should be referred immediately to local law enforcement officials. Other resources in an acute situation include crisis hotlines and rape relief centers.
In Kentucky, there are a number of domestic violence centers that provide 24-hour crisis lines, temporary shelter, counseling, casework services, children's services, hospital/legal advocacy, information and referral services, and support to domestic violence victims and their children. A list of these centers along with the particular counties each center serves is provided here. In addition, domestic violence victims in Kentucky have access to a number of state and national reporting hotlines. These telephone numbers are available following the list of domestic violence centers.
After a victim is introduced into the system, counseling and follow-up is generally available by individual counselors who specialize in the care of domestic violence victims, their spouses, and children. These may include social workers, psychologists, psychiatrists, other mental health workers, and community mental health services. The goals are to make the resources accessible and safe and to enhance support for victims who are unsure of their options.
|Barren River Area Safe Space (BRASS), Inc.|
|P.O. Box 1941, Bowling Green, KY 42102|
|Crisis Only: 800-928-1183 or 270-843-1183|
|Areas Served: Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson, Warren|
|Bethany House Abuse Shelter, Inc.|
|P.O. Box 864, Somerset, KY 42502|
|Crisis Only: 800-755-2017|
|Areas Served: Adair, Casey, Clinton, Cumberland, Green, McCreary, Pulaski, Russell, Taylor, Wayne|
|Green House 17 (previously the Bluegrass Domestic Violence Program)|
|P.O. Box 55190, Lexington, KY 40555|
|Crisis Only: 800-544-2022|
|Areas Served: Anderson, Bourbon, Boyle, Clark, Estill, Fayette, Franklin, Garrard, Harrison, Jessamine, Lincoln, Madison, Mercer, Nicholas, Powell, Scott, Woodford|
|The Center for Women and Families|
|P.O. Box 2048, Louisville, KY 40201|
|Crisis Only: 877-803-7577|
|Areas Served: Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, Trimble|
|DOVES of Gateway|
|P.O. Box 1012, Morehead, KY 40351|
|Crisis Only: 800-221-4361|
|Areas Served: Bath, Menifee, Montgomery, Morgan, Rowan|
|Family Life Abuse Center (Christian Appalachian Project)|
|P.O. Box 654, Mount Vernon, KY 40456|
|Crisis Only: 800-755-5348 or 606-256-2724|
|Areas Served: Bell, Clay, Harlan, Jackson, Knox, Laurel, Rockcastle, Whitley|
|P.O. Box 1867, Hazard, KY 41702|
|Crisis Only: 800-928-3131|
|Areas Served: Breathitt, Knott, Lee, Leslie, Letcher, Owsley, Perry, Wolfe|
|P.O. Box 98, Paducah, KY 42002|
|Crisis Only: 800-585-2686 or 270-443-6001|
|Areas Served: Ballard, Calloway, Carlisle, Fulton, Graves, Hickman, Marshall, McCracken|
|Owensboro Area Shelter and Information Services (OASIS)|
|P.O. Box 315, Owensboro, KY 42302|
|Crisis Only: 800-882-2873 or 270-685-0260|
|Areas Served: Daviess, Hancock, Henderson, McLean, Ohio, Union, Webster|
|P.O. Box 2163, Ashland, KY 41105|
|Crisis Only: 800-926-2150|
|Areas Served: Boyd, Carter, Elliott, Greenup, Lawrence|
|P.O. Box 1165, Hopkinsville, KY 42240|
|Crisis Only: 800-766-0000|
|Areas Served: Caldwell, Christian, Crittenden, Hopkins, Livingston, Lyon, Muhlenberg, Todd, Trigg|
|Sandy Valley Abuse Center, Inc.|
|P.O. Box 1297, Prestonsburg, KY 41653|
|Crisis Only: 800-649-6605|
|Areas Served: Floyd, Johnson, Magoffin, Martin, Pike|
|P.O. Box 2047, Elizabethtown, KY 42702|
|Crisis Only: 800-767-5838 or 270-769-1234|
|Areas Served: Breckinridge, Grayson, Hardin, LaRue, Marion, Meade, Nelson, Washington|
|Women's Crisis Center, Northern Kentucky|
|835 Madison Avenue, Covington, KY 41011|
|Crisis Only: 800-928-3335 or 859-491-3335|
|Areas Served: Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen, Pendleton|
|Women's Crisis Center, Buffalo Trace|
|111 East Third Street, Maysville, KY 41056|
|Crisis Only: 800-928-6708 or|
|Areas Served: Bracken, Fleming, Lewis, Mason, Robertson|
|Adult Protection Branch|
|275 East Main Street, Frankfort, KY 40621|
|Attorney General's Office of Victim Advocacy|
|Capitol Suite 118, 700 Capitol Avenue, Frankfort, KY 40601|
|Department for Behavioral Health, Developmental and Intellectual Disabilities|
|100 Fair Oaks Lane, 4E-B, Frankfort, KY 40621|
|Kentucky Domestic Violence Association|
|111 Darby Shire Circle, Frankfort, KY 40601|
|Adult & Child Abuse Reporting Hotline|
|Alcohol & Drug Abuse Information|
|Kentucky State Police Emergency Hotline|
|Prevent Child Abuse Kentucky|
|Domestic Violence Hotline|
|National Center for Missing and Exploited Children|
|Rape, Abuse, and Incest National Network (RAINN) National Sexual Assault Hotline|
|Victim Information and Notification Everyday (VINE)|
To lump all behavior in chaotic relationships under the category of violence can be misleading to the public. The common image of violence for the majority of people is physical harm, attack, and observable injury. Differentiating types of behavior in intimate relationships is necessary to define consequences related to outcome studies to form an evidence base for treatment. The formulation of accurate definitions is instrumental in designing methodology to compare differences. More accurate and sensitive instruments to measure the depth of the social problem are needed to reveal differences in gender-initiated violence, show the accuracy of occurrences of mutual battering, and quantify post-effects of intimate violence on men, women, and children.
The long-term focus on domestic violence is responsible for major reforms on multiple levels within various systemic functions related to criminal prosecution, legislative views and actions, and healthcare protocols. Given the pervasive nature of abuse in relationships, histories of partners including mental, psychological, and behavioral documentation are vital when determining the causes and effects of abuse. Understanding how historical and cultural belief systems are connected to domestic violence is essential in determining an accurate measurement of intimate violence.
Domestic violence will likely continue to be a significant problem in Kentucky. If abuse is to be prevented, healthcare professionals in all settings must educate themselves and assess all patients for abuse during each visit. For identified victims and perpetrators, healthcare providers must offer prompt intervention and referral information. Through these interventions, healthcare professionals can play a tremendous role in reducing and preventing domestic violence.
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