97914 • Domestic Violence: The Kentucky Requirement

Table of Contents

97914 • Domestic Violence: The Kentucky Requirement

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. DEFINING DOMESTIC VIOLENCE

3. PREVALENCE

4. IDENTIFYING DOMESTIC VIOLENCE IN GROUPS AT RISK

PREGNANT WOMEN

MINORITY WOMEN

CHILDREN

ELDERLY

MEN

SAME-SEX COUPLES

MILITARY FAMILIES

5. SCREENING FOR DOMESTIC VIOLENCE AND ABUSE

REPORTING

CULTURALLY SENSITIVE ASSESSMENT

6. INTERVENTIONS FOR DOMESTIC VIOLENCE

SAFETY PLANNING

LEGAL PROTECTIONS

7. RESOURCES AND REFERRALS

DOMESTIC VIOLENCE CRISIS CENTERS

STATEWIDE SERVICES

ADDITIONAL TOLL-FREE TELEPHONE NUMBERS

8. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

97914 • Domestic Violence: The Kentucky Requirement

Marjorie Conner Allen, BSN, JD

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Because of the number of individuals affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims/survivors of domestic violence. 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/survivors 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/survivors, to offer education, counseling, and referral information.

97914 • Domestic Violence: The Kentucky Requirement

Education Category. Ethics - Human Rights

Release Date. 05/01/2023

Expiration Date. 04/30/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2608 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Because of the number of individuals affected, it is likely that most healthcare professionals will encounter patients in their practice who are victims/survivors of domestic violence. 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/survivors 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/survivors, to offer education, counseling, and referral information.

Audience

This course is designed for all Kentucky healthcare professionals who may intervene to protect victims/survivors of domestic violence.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 3 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. Social workers participating in this intermediate to advanced course will receive 3 Clinical continuing education clock hours. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 3 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program. AACN Synergy CERP Category B.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 29, 2025); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2025; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

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.

Course Objective

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/survivors.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define domestic violence.

2. Recognize the characteristics and dynamics experienced by those groups who are at risk for domestic violence, including pregnant women, children, men, and same-sex couples.

3. Describe how to screen for patients who have a history of being a victim/survivor or perpetrator of domestic violence, including aspects of a culturally sensitive assessment.

4. Outline interventions targeted to victims/survivors of domestic violence.

5. Review resources available for domestic violence victims/survivors.

Faculty

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.

Faculty Disclosure

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.

Division Planners

Ronald Runciman, MD

Sharon Cannon, RN, EdD, ANEF

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

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.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

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/survivors. 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/survivors 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/survivors, to offer education, counseling, and referral information.

Victims/survivors of domestic violence suffer emotional, psychologic, and physical abuse, all of which can result in both acute and chronic signs and symptoms. Victims/survivors may present with physical and mental disease, illness, and injury. Frequently, the injuries sustained require abused victims/survivors to seek care from healthcare professionals immediately after their victimization. Subsequently, physicians and nurses are often the first healthcare providers that victims/survivors encounter and are in a critical position to identify domestic violence victims/survivors in a variety of clinical practice settings where victims/survivors receive care. Healthcare professionals must educate themselves to enhance awareness of domestic violence in each particular practice or clinical setting.

2. DEFINING DOMESTIC VIOLENCE

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) defines IPV as, "physical violence, sexual violence, stalking, and psychologic aggression (including coercive tactics) by a current or former intimate partner (i.e., spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner)" [21].

Domestic violence can consist of any of many behaviors or combination of behaviors, falling under physical, psychologic, verbal, sexual, and financial/economic abuse (Table 1).

Table 1: DOMESTIC VIOLENCE BEHAVIORS

Physical Abuse

Psychologic/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/survivor's movement, stalking, threats, threatening to hurt victim's/survivor'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 victims/survivors to open bank account, all property is in the perpetrator's name, victim/survivor is not allowed to work

Source: Compiled by Authors

The state of Kentucky has formulated the following definitions [2]:

- "Domestic violence and abuse" refers to physical injury, serious physical injury, stalking, sexual abuse, strangulation, assault, or the infliction of fear of imminent physical injury, serious physical injury, sexual abuse, strangulation, 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/survivor.

- "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 psychologic 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.

3. PREVALENCE

Since the 1970s, domestic violence has emerged as one of the most serious public health problems facing women in this country [1]. According to the CDC's 2016/2017 National Intimate Partner and Sexual Violence Survey, almost 1 in 2 women (47.3%) and more than 2 in 5 men (44.2%) in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime[3]. Although many of these incidents consist of pushing, grabbing, shoving, slapping, and hitting, 32.5% of female and 24.6% of male victims/survivors of intimate partner violence experienced severe physical violence. In addition, 16% victims of homicide are killed by a current or former intimate partner[1,5].

According to the Kentucky Cabinet for Health and Family Services, individuals in Kentucky are more likely to experience IPV than the national average[6]. The most recent data indicates that nearly half (45.3%) of women and one-third (35.5%) of men in Kentucky reported having been the victim/survivor of IPV [68]. It is also estimated that one in nine women in Kentucky will be the victim/survivor of sexual assault in their lifetime[6]. In one day in 2019, 1,420 victims/survivors of abuse were sheltered by various types of programs in Kentucky, but an additional 128 requests for service were denied due to lack of resources[68]. In the United States, it is estimated that 30% of all female and 5% of male murder victims are killed by intimate partners[7]. 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[8]. Furthermore, 72% of all murders/suicides involved an intimate partner, with the overwhelming majority (94%) involving a female victim[68]. 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[9].

Victims/survivors 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[1]. 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/survivors 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]. An analysis of the 2012 National Intimate Partner and Sexual Violence Survey showed that victims/survivors of domestic violence lost 741 million days of productivity, a total of $110 billion across the lifetimes of all victims/survivors[4].

The rate of serious domestic violence against women has declined significantly from 1994 to 2018, from nearly 6.9 million females 12 years of age or older in 1994 to nearly 3.3 million in 2018[11]. The rate of overall family violence also fell by more than one-half in this time period[11]. 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].

4. IDENTIFYING DOMESTIC VIOLENCE IN GROUPS AT RISK

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 individuals. Although women are most often the victims/survivors 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.

PREGNANT WOMEN

Because a gynecologist or obstetrician is frequently a woman's primary care physician, these healthcare providers should be particularly sensitive to domestic violence issues [15]. According to the CDC, IPV affects as many as 324,000 pregnant women each year[16]. 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[16]. 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. One study found that pregnant women who had been treated at a hospital after a violent incidence had an eight-fold increased risk of fetal death[69]. 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 psychologic consequences of abuse during pregnancy. There is a higher risk of stress, depression, and addiction to alcohol and drugs in abused women, and victims/survivors are less likely to obtain prenatal care and to develop postpartum depression[20,69,70].

MINORITY WOMEN

The United States is becoming increasingly diverse in terms of ethnic composition. By 2044, the U.S. will become a majority-minority nation [71]. In 2021, 13.6% of the U.S. population was foreign-born, most of whom reside in the West[72]. 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[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[22]. 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[23]. In a qualitative study of 10 Mexican women who experienced IPV, immigration status (specifically the fear of deportation) was the primary reason they did not leave the relationship or seek help[73].

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[24]. Research indicates that perpetrators in these cases are overwhelmingly male[74]. 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[25].

CHILDREN

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/survivors 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%)[27]. 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)[29]. In addition to witnessing violence, these children may also become direct victims/survivors of violence, as child maltreatment occurs in 30% to 60% of families in which IPV is reported[30]. Moreover, statistics demonstrate that 85% of domestic violence victims/survivors abuse or neglect their children.

Indirect exposure to violence may also have consequences. In one study, children whose mothers were victims/survivors of IPV exhibited externalizing problems regardless of whether they directly witnessed the violence[75]. The researchers concluded that the children may sense and internalize their mothers' psychologic distress[75].

Adolescents are also victimized. Between 7% and 17.5% of all homicides against girls 12 to 17 years of age are committed by an intimate partner[31,12]. 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[32]. 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.

Adverse childhood experiences (including domestic violence) contribute to lifelong negative emotional, physical, and behavioral consequences. These adverse childhood experiences appear to be dose-related, in that the more traumatic the childhood experiences, the more severe the outcomes will be in later life[76]. In addition, if the stressors endure over a long period of time (referred to as "toxic stress"), it can lead to negative changes to the brain[76].

ELDERLY

Abused and neglected elders, who may be mistreated by their spouses, partners, children, and other relatives, are among the most isolated of all victims/survivors of family violence. Among the elderly, it is estimated that 1 in 10 individuals will experience at least one form of abuse (e.g., physical, psychologic, financial, sexual, neglect) [34]. Those 65 years of age and older are projected to number 83.7 million in the United States by 2050, almost double the number in 2012, exponentially increasing the number of individuals experiencing elder abuse[34].

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/survivors are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected[77]. Healthcare professionals in all settings must remain aware of the potential for abuse and keep a watchful eye on this growing and particularly vulnerable group.

MEN

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 [35]. Studies demonstrate that approximately 5% of murdered men are killed by intimate partners[31]. It is persuasively argued that the impact on the health of female victims/survivors of domestic violence is generally much more severe than the impact on the health of male victims/survivors[36]. However, approximately 7% of men are raped and/or physically assaulted by an intimate partner in their lifetime[3,24]. In 2008, men experienced 101,000 nonfatal violent victimizations by an intimate partner[37]. Healthcare professionals should always keep in mind that men can also be victimized and experience mental health consequences of the abuse. Because IPV is perceived as a "woman's issue," men who are victims/survivors of IPV may perceive the experience as a threat to their manhood[78].

SAME-SEX COUPLES

Domestic violence exists in the gay, lesbian, bisexual, transgender, and other gender and sexual minorities (LGBT+) 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 [38]. The lifetime prevalence rate of psychologic abuse was 59% for gay men and 53% for bisexual men[38]. Men living with male intimate partners experience significantly more IPV than men who live with female intimate partners[4]. This supports other statistics indicating that IPV is perpetrated primarily by men. Three dominant barriers to help-seeking by LGBT+ victims/survivors have been identified: lack of understanding of the problem, stigma, and systemic inequities[80]. In general, much of the IPV literature and knowledge base has focused on heterosexual women's experiences with IPV. Furthermore, because of the stigma of being gay, victims/survivors 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/survivor feeling isolated and unsupported. Healthcare professionals should strive to be sensitive and supportive when working with homosexual patients.

MILITARY FAMILIES

As with domestic violence in the civilian population, military victims/survivors 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/survivors found when they did report abuse, military personnel were not sensitive to their needs [39]. 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[40]. 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[40]. Reports from the Congressional Research Service indicate that among the active-duty population, there were 16,912 reported incidents of spouse and intimate partner abuse in 2018[33]. Among these, 8,039 reports (6,372 victims/survivors) met the Department of Defense definitions. Physical abuse accounted for the highest number of reports (73.7%), followed by emotional abuse (22.6%), sexual abuse (3.6%), and neglect (0.06%)[33].

The Family Advocacy Program is responsible for seeing that victims/survivors remain safe and have access to support and advocacy services and that offenders receive appropriate intervention services[41]. 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/survivors 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[42].

Presence of a psychiatric disorder can also increase the risk of domestic violence in military families. In one systematic review, 27.5% of male veterans with PTSD disclosed to perpetrating physical violence in the last year, and 91% reported using psychologic violence against their partner[81]. Male members of the military with depression had a 3.95 increased likelihood of perpetrating physical violence against their partner compared to men without a mental disorder[81].

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.

5. SCREENING FOR DOMESTIC VIOLENCE AND ABUSE

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[47]. 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[48].

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[49]. 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, lack of consensus on screening guidelines, and lack of office protocols[48,50,82]. 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[51].

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force recommends that clinicians screen for intimate partner violence in women of reproductive age and provide or refer women who screen positive to ongoing support services.

https://jamanetwork.com/journals/jama/fullarticle/2708121

Last Accessed: April 27, 2023

Level of Evidence: B (There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.)

It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims/survivors. In a 2016 study of 288 healthcare facilities in Florida, 78% understood the importance of IPV screening and had some type of IPV screening policy institute in their setting[82]. However, many of the respondents did not know which screening tool was used or the types of screening questions asked. 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/survivors 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/survivors were 13 times more likely to sustain injury to breast, chest, or abdomen than accident victims/survivors. Abuse victims/survivors are also more likely to have multiple injuries than accident victims/survivors. When this pattern of injuries is seen in a patient, particularly in combination with evidence of old injury, physical abuse should be suspected[19].

In addition to physical signs and symptoms, domestic violence victims/survivors also exhibit psychologic cues that resemble an agitated depression. As a result of prolonged stress, victims/survivors 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, healthcare professionals may respond to these women by diagnosing the patient to be neurotic or irrational[36]. Healthcare professionals should cast aside these misperceptions of abused victims/survivors and work within their respective practice settings to develop screening mechanisms to detect women who exhibit these symptoms. In addition, it is important to recognize that vulnerable populations, including LGBT+ individuals, those with HIV, individuals with disabilities, and veterans are also at risk and should be screened for IPV[83].

For every victim/survivor of abuse, there is also a perpetrator. Like their victims/survivors, perpetrators of domestic violence come from all socioeconomic backgrounds, races, religions, and walks of life[53]. Accordingly, healthcare professionals must be aware that seemingly supportive family members may, in fact, be abusers. Perpetrators and their victims/survivors 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[53].

Abuser characteristics have been studied far less frequently than victim/survivor 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[54]. Screening questionnaires should include questions that explore social drinking habits of both the victim/survivor 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, also referred to as intrusiveness (i.e., overdependence on controlling behaviors)[84]. In a study of 342 lesbian women, high levels of intrusiveness were correlated with higher incidences of perpetrating physical violence[84]. This characteristic may be so extreme as to border on paranoia[53]. In addition, domestic violence victims/survivors 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"[55]. In addition, healthcare professionals should be on the lookout for perpetrators 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"[52].

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[56].

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/survivors and medical care (e.g., primary care, emergency services, obstetric and gynecologic services, psychiatric services, pediatric care)[19].

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[57]. After such treatment is rendered, however, it is important that healthcare professionals not ignore the reasons that brought the victim/survivor 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/survivors 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/survivor'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)[22].

Table 2: STRUCTURED INTERVIEW FOR TREATMENT PLANNING

1. How were you hurt?

2. Has this happened before?

3. When did it first happen?

4. How badly have you been hurt in the past?

5. Was a weapon involved? Is there a weapon in your residence?

6. What kind of weapon?

7. Who lives in your residence?

8. What are the children's ages?

9. Are the children in danger?

10. Have they been hit or hurt by the perpetrator?

11. How badly have they been hit or hurt?

12. Have you ever told anyone about this before? If so, who?

13. What have you done in the past to protect yourself?

14. What have you done in the past to get help?

15. Have you ever called the police?

16. If yes, when and what did they say/do?

17. Did you report this incident to the police? If not, why not?

18. If yes, what precinct?

19. What did they say/do?

20. Have you ever obtained a protective order?

21. Have you tried to press charges this time or before?

22. Does the perpetrator have a criminal record?

23. Has he/she beaten or hurt other people?

24. Has he/she threatened to kill you?

25. Has he/she tried to kill you?

26. If so, what did he/she do?

27. Are you afraid to go home?

28. Where can you go?

29. Have you ever called a crisis center for help?

30. If so, who is your contact person there?

31. If not, why not?

32. Do you know the phone number of the local crisis center?

Source: [46]

After the history is obtained and initial treatment is started, it is imperative to document all findings and recommendations in the individual's medical record. The medical record can be invaluable in establishing the credibility of the domestic violence victim's/survivor's story when he or she seeks legal aid [57].

REPORTING

Kentucky law mandates the reporting of the abuse or neglect of children and elderly and/or vulnerable adults (i.e., those with a physical or mental disability) to the Cabinet for Health and Family Services, the state or local police, and/or the local prosecutor's office [58,60]. However, as of June 2017, Kentucky's law mandating reporting of suspected domestic or dating violence changed to a mandatory information and referral position[85].

According to the revised statute, if a professional has reasonable cause to believe that a person has experienced domestic violence or dating violence, the professional shall provide the individual with information about the regional domestic violence program or rape crisis center and information on how to access protective orders[86]. This is limited to persons with whom the professional has a professional interaction (as opposed to any contact whatsoever). In addition, a professional may report to a law enforcement agency at the request of a victim/survivor, but a report should not be made if the individual objects[86].

If a healthcare professional knowingly and willfully fails to report a case of suspected child or elder abuse as mandated by the law, then he or she can be subject to criminal penalties[58]. 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[59].

CULTURALLY SENSITIVE ASSESSMENT

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 [61]. 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[62]. 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[62]. 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[62]. 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, biologic, 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/survivors or perpetrators of domestic violence, it may be possible to intervene and offer treatment more effectively.

6. INTERVENTIONS FOR DOMESTIC VIOLENCE

SAFETY PLANNING

All practitioners who deal with domestic violence should periodically review safety planning with victims/survivors. Homicide is of high risk for victims/survivors; therefore, safety planning is crucial. When advocating a safety plan, it is important to:

- Encourage the victim/survivor to be aware of weapons in the residence.

- Have victims/survivors 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/survivors should save some money in a private bank account or hide money for escape. Victims/survivors should be informed that if the abuser finds out about a separate bank account, they could be in danger.

- Encourage victims/survivors to keep a bag packed with necessities and stored in a safe place in the event leaving must be immediate.

- Advise victims/survivors to work out a code word or signal with the children so they will know when to implement an escape plan.

- Encourage victims/survivors 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/survivors will employ safety planning guidelines.

It is important to note that general safety planning does not take into account the specific needs of victims/survivors who fall into vulnerable populations or affected children [87]. Because these individuals are at higher risk of marginalization and oppression, they may feel powerless to execute a safety plan. It is important for practitioners to assess each IPV victim/survivor and his/her readiness to change, circumstances, resources, and needs in order to tailor a specific safety plan[88].

LEGAL PROTECTIONS

If a victim/survivor 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/survivors 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. In cases of dating violence and stalking/sexual assault cases, a temporary interpersonal protective order can be filed [79]. Protective orders can be filed at the Office of Circuit Court Clerk in the county of residence (or temporary residence). Each county's contact information is available athttps://courts.ky.gov/courts/clerks [79].

The batterer will not be present at the hearing, and the victim/survivor 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/survivor 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 individual 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[63].

Kentucky law provides that a judge can enter an emergency protective order or a domestic violence order that[64]:

- Restrains the batterer from any unauthorized contact or communication with the petitioner or other person specified 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 [65].

The court reviews petitions for protective orders on filing and schedules an evidentiary hearing within 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/survivor[66]. 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/survivor 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[67]. If the batterer is no longer present when the police arrive, the victim/survivor should request that a report of the violation, and of any other crimes, be written. The victim/survivor 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[63]. If the county has a Global Positioning System (GPS) monitoring service, the victim/survivor can request the court to order the batterer to wear a GPS device by filing a motion form, which will be evaluated by a judge[79].

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/survivors 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[63]. Victims/survivors 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/survivors may be called to testify at an evidentiary hearing or at trial. If a victim/survivor 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/survivors are again required to testify[63]. 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/survivor restitution; mandatory counseling; mediation; substance-abuse treatment; or public service[63].

7. RESOURCES AND REFERRALS

After identifying victims/survivors 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/survivor and their 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/survivors and their children. A list of these centers along with the particular counties each center serves is provided here. In addition, domestic violence victims/survivors 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/survivor is introduced into the system, counseling and follow-up is generally available by individual counselors who specialize in the care of domestic violence victims/survivors, 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 people who are unsure of their options.

DOMESTIC VIOLENCE CRISIS CENTERS

Barren River Area Safe Space (BRASS), Inc.

P.O. Box 1941, Bowling Green, KY 42102

Phone: 270-781-9334

Crisis Only: 800-928-1183 or 270-843-1183

https://www.brassinc.org

Areas Served: Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson, Warren

Bethany House Abuse Shelter, Inc.

Phone: 606-679-1553

Crisis Only: 800-755-2017

http://bethanyhouseinc.org

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

Phone: 859-233-0657

Crisis Only: 800-544-2022

https://www.greenhouse17.org

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

Phone: 502-581-7200

Crisis Only: 1-844-BESAFE1

https://www.thecenteronline.org

Areas Served: Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, Trimble

DOVES of Gateway

P.O. Box 1012, Morehead, KY 40351

Phone: 606-784-6880

Crisis Only: 800-221-4361

https://dovesofgateway.org

Areas Served: Bath, Menifee, Montgomery, Morgan, Rowan

Hazard-Perry County Community Ministries, Inc.

151 Miss Edna Lane, Hazard, KY 41702

Phone: 606-436-2662

Areas Served: Perry

LKLP Safehouse

398 Roy Campbell Dr., Hazard, KY 41702

Phone: 606-436-8853

https://www.lklp.org

Areas Served: Leslie, Knott, Letcher, Perry

Merryman House

P.O. Box 98, Paducah, KY 42002

Phone: 270-443-6001

Crisis Only: 800-585-2686

https://merrymanhouse.org

Areas Served: Ballard, Calloway, Carlisle, Fulton, Graves, Hickman, Marshall, McCracken

Owensboro Area Shelter and Information Services (OASIS)

Phone: 270-685-0260

Crisis Only: 800-882-2873

https://www.oasisshelter.org

Areas Served: Daviess, Hancock, Henderson, McLean, Ohio, Union, Webster

Safe Harbor/FIVCO

P.O. Box 2163, Ashland, KY 41105

Phone: 606-329-9304

Crisis Only: 800-926-2150

https://www.safeharborky.org

Areas Served: Boyd, Carter, Elliott, Greenup, Lawrence

Sanctuary, Inc.

P.O. Box 1165, Hopkinsville, KY 42240

Phone: 270-885-4572

Crisis Only: 800-766-0000

https://thesanctuaryinc.com

Areas Served: Caldwell, Christian, Crittenden, Hopkins, Livingston, Lyon, Muhlenberg, Todd, Trigg

TurningPoint Domestic Violence Services

P.O. Box 1297, Prestonsburg, KY 41653

Phone: 606-886-6025

Crisis Only: 800-649-6605

https://www.turningpointky.org

Areas Served: Floyd, Johnson, Magoffin, Martin, Pike

SpringHaven, Inc.

Phone: 270-769-1234

Crisis Only: 800-767-5838

http://www.springhaveninc.org

Areas Served: Breckinridge, Grayson, Hardin, LaRue, Marion, Meade, Nelson, Washington

Ion Center for Violence Prevention, Northern Kentucky

835 Madison Avenue, Covington, KY 41011

24-hour Hotline: 859-491-3335

https://ioncenter.org

Areas Served: Boone, Campbell, Carroll, Gallatin, Grant, Kenton, Owen, Pendleton

Ion Center for Violence Prevention, Maysville

111 East Third Street, Maysville, KY 41056

24-hour Hotline: 606-564-6708

https://ioncenter.org

Areas Served: Bracken, Fleming, Lewis, Mason, Robertson

STATEWIDE SERVICES

Adult Protection Branch

Cabinet for Health and Family Services

275 East Main Street, Frankfort, KY 40621

Phone: 502-564-5497

https://chfs.ky.gov/agencies/dcbs/dpp/apb

Attorney General's Office of Victim Advocacy

700 Capitol Avenue, Capitol Suite 118, Frankfort, KY 40601-3449

Phone: 800-372-2551

https://ag.ky.gov

Department for Behavioral Health, Developmental and Intellectual Disabilities

275 E. Main Street 4WF, Frankfort, KY 40621

Phone: 502-564-4527

http://dbhdid.ky.gov/kdbhdid

Kentucky Coalition Against Domestic Violence

111 Darby Shire Circle, Frankfort, KY 40601

Phone: 502-209-5382

https://kcadv.org

ADDITIONAL TOLL-FREE TELEPHONE NUMBERS

Kentucky Adult & Child Abuse Reporting Hotline

877-597-2331

Alcohol & Drug Abuse Information

800-432-9337

800-729-6686

Kentucky State Police Emergency Hotline

800-222-5555

Prevent Child Abuse Kentucky

800-CHILDREN (244-5373)

Domestic Violence Hotline

800-799-SAFE (7233)

TDD 800-787-3224

National Center for Missing and Exploited Children

800-THE-LOST (843-5678)

Rape, Abuse, and Incest National Network (RAINN) National Sexual Assault Hotline

800-656-HOPE (4673)

Victim Information and Notification Everyday (VINE)

800-511-1670

8. CONCLUSION

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, psychologic, 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/survivors 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.

Works Cited

1. National Center for Injury Prevention and Control. Costs of Intimate Partner Violence Against Women in the United States.Atlanta, GA: Centers for Disease Control and Prevention; 2003.

2. Kentucky Revised Statute 403.720 Definitions for KRS 403.715 to 403.785.

3. Centers for Disease Control and Prevention. The National Intimate Partner and Sexual Violence Survey: 2016/2017 Data Brief. Available at https://www.cdc.gov/violenceprevention/pdf/nisvs/NISVSReportonIPV_2022.pdf. Last accessed April 24, 2023.

4. Peterson C, Liu Y, Kresnow MJ, et al. Short-term lost productivity per victim: intimate partner violence, sexual violence, or stalking. Am J Prev Med.2018;55(1):106-110.

5. Centers for Disease Control and Prevention. Preventing Intimate Partner Violence. Available at https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html. Last accessed April 24, 2023.

6. Cook P, Morris Mandel F, Kelly N, for the Kentucky Statewide Strategic Planning Committee for Violence Prevention. Statewide Strategic Plan for the Prevention for Sexual Assault, Domestic Violence and Child Abuse—2006.Frankfort, KY: Kentucky Cabinet for Health and Family Services; 2006.

7. Bureau of Justice Statistics. Intimate Partner Violence in the U.S. Available at https://bjs.ojp.gov/content/pub/pdf/fvs02.pdf. Last accessed April 24, 2023.

8. Walsh S, Hemenway D. Intimate Partner Violence: Homicides Followed by Suicides in Kentucky. Available at https://kvdrs.ky.gov/Documents/Intimate%20Partner%20Violence%20Homicides%20Followed%20by%20Suicides%20in%20Kentucky.pdf. Last accessed April 24, 2023.

9. Kentucky Revised Statute 194A.540 Cabinet's Manner of Addressing Child Abuse, Child Neglect, Domestic Violence, Rape, and Sexual Assault: Coordination, Consultation, Recommendations, and Training.

10. Max W, Rice DP, Finkelstein E, Bardwell RA, Leadbetter S. The economic toll of intimate partner violence against women in the United States. Violence Vict.2004;19(3):259-272.

11. Morgan RE, Oudekerk BA. Bureau of Justice Statistics: Criminal Victimization, 2018. Available at https://bjs.ojp.gov/library/publications/criminal-victimization-2018. Last accessed April 24, 2023.

12. Adhia A, Kernic MA, Hemenway D, Vavilala MS, Rivara FP. Intimate partner homicide of adolescents. JAMA Pediatr.2019;173(6):571-577.

13. National Institute of Justice. The decline of intimate partner homicide. National Institute of Justice Journal.2005;252:33-34.

14. Farmer A, Tiefenthaler J. Explaining the recent decline in domestic violence. Contemp Econ Policy.2003;21(2):158-172.

15. Lutgendorf MA, Thagard A, Rockswold PD, Busch JM, Magann EF. Domestic violence screening of obstetric triage patients in a military population. J Perinatol.2012;32(10):763-769.

16. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. Committee Opinion: Intimate Partner Violence (Reaffirmed 2022). Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/02/intimate-partner-violence. Last accessed April 24, 2023.

17. Chu SY, Goodwin MM, D'Angelo DV. Physical violence against U.S. women around the time of pregnancy, 2004–2007. Am J Prev Med.2010;38(3):317-322.

18. McFarlane J, Maddoux J, Cesario S, et al. Effect of abuse during pregnancy on maternal and child safety and functioning for 24 months after delivery. Obstet Gynecol.2014;123(4):839-847.

19. American Medical Association Council on Scientific Affairs. Violence against women: relevance for medical practitioners. JAMA.1992;267:3184-3189.

20. Chambliss LR. Intimate partner violence and its implication for pregnancy. Clin Obstet Gynecol.2008;51(2):385-397.

21. Centers for Disease Control and Prevention. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0. Available at https://www.cdc.gov/violenceprevention/pdf/intimatepartnerviolence.pdf. Last accessed April 24, 2023.

22. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of Intimate Partner Violence Against Women: Findings from the National Violence Against Women Survey. Available at https://www.ojp.gov/pdffiles1/nij/183781.pdf. Last accessed April 24, 2023.

23. Lown EA, Vega WA. Prevalence and predictors of physical partner abuse among Mexican American women. Am J Public Health.2001;91(3):441-445.

24. American Bar Association Commission on Domestic Violence. Domestic Violence Statistics. Available at https://www.americanbar.org/groups/domestic_violence. Last accessed April 24, 2023.

25. Green JW. Help-seeking behavior: the cultural construction of care. In: Green JW (ed). Cultural Awareness in the Human Services: A Multi-Ethnic Approach.3rd ed. Needham Heights, MA: Allyn and Bacon; 1998: 49-79.

26. Resource Center on Domestic Violence. Prevalence Statistics and Resources. Available at https://www.rcdvcpc.org/prevalence-statistics-home.html. Last accessed April 24, 2023.

27. Fox CL, Corr M-L, Gadd D, Butler I. Young Teenagers' Experiences of Domestic Abuse. Available at http://www.boystomenproject.com/wp-content/uploads/2013/04/Poster-Experiences-of-DA.pdf. Last accessed April 24, 2023.

28. Voisin DR, Hong JS. A meditational model linking witnessing intimate partner violence and bullying behaviors and victimization among youth. Educ Psychol Rev.2012;24(4):479-498.

29. Rivas MA. The relationship between exposure to intimate partner violence, behavior problems and weight status in preschool age children in Head Start programs. McNair Scholars Research Journal.2013;6(1):10.

30. Edleson JL. The Overlap between Child Maltreatment and Woman Abuse. Available at https://vawnet.org/material/overlap-between-child-maltreatment-and-woman-abuse. Last accessed April 24, 2023.

31. Cooper A, Smith EL. Homicide Trends in the United States, 1980–2008.Washington, DC: Bureau of Justice Statistics; 2011. Available at https://www.bjs.gov/content/pub/pdf/htus8008.pdf. Last accessed April 24, 2023.

32. U.S. Bureau of Justice. Violence Rates Among Intimate Partners Differ Greatly According to Age. Available at https://bjs.ojp.gov/press-release/intimate-partner-violence-and-age-victim-1993-99. Last accessed April 24, 2023.

33. Congressional Research Service. Military Families and Intimate Partner Violence: Background and Issues for Congress. Available at https://fas.org/sgp/crs/natsec/R46097.pdf. Last accessed April 24, 2023.

34. National Center on Elder Abuse. Statistics and Data. Available at https://ncea.acl.gov/About-Us/What-We-Do/Research/Statistics-and-Data. Last accessed April 24, 2023.

35. Wallace R. Identifying potential challenges to providing emergency advocacy services to male victims of intimate partner violence. Partner Abuse.2014;5(1):58-68.

36. American Medical Association Council on Ethical and Judicial Affairs. Physicians and domestic violence: ethical considerations. JAMA.1992;267:3190-3193.

37. Catalano S, Smith E, Snyder H. Female Victims of Violence. Available at https://bjs.ojp.gov/content/pub/pdf/fvv.pdf. Last accessed April 24, 2023.

38. National Center for Injury Prevention and Control. NISVS 2010 Findings on Victimization by Sexual Orientation. Available at https://www.cdc.gov/violenceprevention/pdf/nisvs_sofindings.pdf. Last accessed April 24, 2023.

39. Erez E, Bach S. Immigration, domestic violence, and the military: the case of "military brides.. Violence Against Women.2003;9(9): 1093-1117.

40. U.S. Government Accountability Office. Military Personnel: Sustained Leadership and Oversight Needed to Improve DOD's Prevention and Treatment of Domestic Abuse. Available at https://www.gao.gov/assets/gao-10-923.pdf. Last accessed April 24, 2023.

41. Military One Source. Family Advocacy Program. Available at https://www.militaryonesource.mil/benefits/family-advocacy-program. Last accessed April 24, 2023.

42. Brewster AL. Evaluation of spouse abuse treatment: description and evaluation of the Air Force family advocacy programs for spouse physical abuse. Mil Med.2002;167(6):464-469.

43. McCarroll JE, Ursano RJ, Liu X, et al. Deployment and the probability of spousal aggression by U.S. Army soldiers. Mil Med.2010;175(5):352-356.

44. Gerlock AA. Domestic violence and post-traumatic stress disorder severity for participants of a domestic violence rehabilitation program. Mil Med.2004;169(6):470-474.

45. Jecker NS. Privacy beliefs and the violent family: extending the ethical argument for physician intervention. JAMA.1993;269:776-780.

46. Sugg NK, Inui T. Primary care physicians' response to domestic violence. JAMA.1992;267:3157-3160.

47. Klap R, Tang L, Wells K, Starks SL, Rodriguez M. Screening for domestic violence among adult women in the United States. J Gen Intern Med.2007;22(5):579-584.

48. Stayton CD, Duncan MM. Mutable influences on intimate partner abuse in health care settings: a synthesis of the literature. Trauma, Violence, and Abuse.2005;6(4):271-285.

49. U.S Preventive Services Task Force. Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening. Available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening. Last accessed April 24, 2023.

50. Jaffee KD, Epling JW, Grant W, Ghandour RM, Callendar E. Physician-identified barriers to intimate partner violence screening. J Womens Health (Larchmt).2005;14(8):713-720.

51. Boinville MA. ASPE Policy Brief: Screening for Domestic Violence in Health Care Settings. Available at https://aspe.hhs.gov/reports/screening-domestic-violence-health-care-settings-0. Last accessed April 24, 2023.

52. Scherer DD. Tort remedies for victims of domestic abuse. S C Law Rev.1992;43:543-579.

53. Sonkin DJ, Martin D, Walker LE. The Male Batterer: A Treatment Approach.New York, NY: Springer Publishing Company; 1985.

54. Sedlak AJ. Prevention of wife abuse. In: Van Hasselt VB, Morrison RL, Bellack AS, Hersen M (eds). Handbook of Family Violence.New York, NY: Plenum Press; 1988: 319-358.

55. Fischer K, Vidmar N, Ellis R. The culture of battering and the role of mediation in domestic violence cases. SMU Law Rev.1993;46:2117-2174.

56. Okun L. Woman Abuse: Facts Replacing Myths.Albany, NY: State University of New York Press; 1986.

57. Krimm J, Heinzer MM. Domestic violence screening in the emergency department of an urban hospital. J Natl Med Assoc.2002;94(6):484-491.

58. Kentucky Revised Statute Chapter 209 Administrative regulations—Reports of adult abuse, neglect, or exploitation—Cabinet actions—Status and disposition reports.

59. Kentucky Revised Statute Chapter 209.050 Immunity from civil or criminal liability.

60. Kentucky Revised Statute 620.030 Duty to Report.

61. Panos PT, Panos AJ. A model for a culture-sensitive assessment of patients in health care settings. Soc Work Health Care.2000;31(1):49-62.

62. Pachter LM. Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery. JAMA.1994;271(9):690-695.

63. Warshaw C. Legal protections for battered women. In: Lee D, Durborow N, Salber PR (eds). Improving the Health Care Response to Intimate Partner Violence: A Resource Manual for Health Care Providers.San Francisco, CA: Family Violence Prevention Fund; 1995.

64. Kentucky Revised Statute 403.740 Dissolution of Marriage—Child Custody—Domestic Violence Order—Restrictions—Temporary Child Support—Expiration and Reissuance.

65. Kentucky Revised Statute 403.763 Violation of Order of Protection Constitutes Contempt of Court and Criminal Offense.

66. Kentucky Revised Statute 403.725 Petition for Order of Protection—Venue—Verified Contents—Concurrent Jurisdiction—Protocols for Access and Supplemental Jurisdiction—Referral.

67. Kentucky Revised Statute 403.785 Duties of Law Enforcement Officers and Agencies.

68. National Coalition Against Domestic Violence. Domestic Violence in Kentucky. Available at https://assets.speakcdn.com/assets/2497/ncadv_kentucky_fact_sheet_2020.pdf. Last accessed April 24, 2023.

69. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health.2015;24(1):100-106.

70. Flanagan JC, Gordon KC, Moore TM, Stuart GL. Ethnic women's stress, depression, and relationship adjustment profiles as they relate to intimate partner violence and mental health during pregnancy and postpartum. Psychol Violence.2015;5(1):66-73.

71. U.S. Census Bureau. Hispanic Heritage Month 2016. Available at https://www.census.gov/newsroom/facts-for-features/2016/cb16-ff16.html. Last accessed April 24, 2023.

72. U.S. Census Bureau. Selected Social Characteristics in the United States. Available at https://data.census.gov/table?q=foreign+ born&tid=ACSDP1Y2021.DP02. Last accessed April 24, 2023.

73. Reina A, Lohman B. Barriers preventing Latina immigrants from seeking advocacy services for domestic violence victims: a qualitative analysis. J Fam Violence.2015;30(4):479-488.

74. Sabri B, Campbell JC, Dabby FC. Gender differences in intimate partner homicides among ethnic sub-groups of Asians. Violence Against Women.2016;22(4):432-453.

75. Jouriles EN, McDonald R, Vu NL, Sargent KS. Children's exposure to intimate partner violence: should sexual coercion be considered. J Fam Psychol.2016;30(4):503-508.

76. De Jong AR. Domestic violence, children, and toxic stress. Widener Law Review.2016;22(2):201-213.

77. Band-Winterstein T. Aging in the shadow of violence: a phenomenological conceptual framework for understanding elderly women who experienced lifelong IPV. J Elder Abuse Negl.2015;27(4-5):303-327.

78. Hines DA, Douglas EM. Relative influence of various forms of partner violence on the health of male victims: study of a help seeking sample. Psychol Men Masc.2016;17(1):3-16.

79. Commonwealth of Kentucky Administrative Office of the Courts. How to Obtain a Protective Order. Available at https://kycourts.gov/Legal-Help/Documents/P123ProtectiveOrderBooklet.pdf. Last accessed April 24, 2023.

80. Calton JM, CattaneoLB, Gebhard KT. Barriers to help seeking for lesbian, gay, bisexual, transgender, and queer survivors of intimate partner violence. Trauma Violence Abuse.2016;17(5):585-600.

81. Trevillion K, Williamson E, Thandi G, Borschmann R, Oram S, Howard LM. A systematic review of mental disorders and perpetration of domestic violence among military populations. Soc Psychiatry Psychiatr Epidemiol.2015;50(9):1329-1346.

82. Williams JR, Halstead V, Salani D, Koermer N. Intimate partner violence screening and response: policies and procedures across health care facilities. Womens Health Issues.2016;26(4):377-383.

83. Ghandour RM, Campbell JC, Lloyd J. Screening and counseling for intimate partner violence: a vision for the future. J Womens Health.2015;24(1):57-61.

84. Mason TB, Lewis RJ, Gargurevich M, Kelley ML. Minority stress and intimate partner violence perpetration among lesbians: negative affect, hazardous drinking, and intrusiveness as mediators. Psychol Sex Orientat Gend Divers.2016;3(2):236-246.

85. Kentucky Coalition Against Domestic Violence. Mandatory Reporting. Available at https://kcadv.org/resources/laws/mandatory-reporting. Last accessed March 6, 2020.

86. Kentucky Coalition Against Domestic Violence. Domestic Violence and Dating Violence Education & Referral Act: Proposal to the 2017 General Assembly. Available at https://kcadv.org/sites/kcadv.org/files/sites/kcadv.org/files/SB%2086%20Comparison%20Chart.pdf. Last accessed April 24, 2023.

87. Murray CE, Horton GE, Johnson CH, et al. Domestic violence service providers' perceptions of safety planning: a focus group study. J Fam Violence.2015;30(3):381-392.

88. Parker EM, Gielen AC. Intimate partner violence and safety strategy use: frequency of use and perceived effectiveness. Womens Health Issues.2014;24(6):584-593.

Evidence-Based Practice Recommendations Citations

1. U.S. Preventive Services Task Force. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: U.S. Preventive Services Task Force final recommendation statement. JAMA. 2018;320(16):1678-1687. Available at https://jamanetwork.com/journals/jama/fullarticle/2708121. Last accessed April 27, 2023.