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Updated Domestic Violence and Healthcare Professionals

Domestic Violence and Healthcare Professionals

Michelle Jewett

on 7 April 2014

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Transcript of Updated Domestic Violence and Healthcare Professionals

Understanding Domestic Violence
for the
Healthcare Professional

What is
Domestic Violence
(also known as Intimate Partner Violence)?
Legal Definition
Any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any other criminal offense that results in physical injury or death of one family or household member by another.
FS XLIII Chapter 741.28
Domestic violence is the increasingly frequent and severe cycle of physical, verbal, emotional, psychological, spiritual, and sexual abuse for the purpose of establishing and maintaining power and control
Every 9 seconds in the U.S., a woman is assaulted or beaten by someone she loves.

Everyday in the U.S., more than three women are murdered by their partners.

Females who are 20-24 years of age are at the greatest risk of nonfatal intimate partner violence.
Domestic Violence happens in one in four American families.
Who is the Face of Domestic Violence?
Any Race, Any Religion, Any Culture,
Any Sexual Orientation, Any Financial Status,
Any Where!
Dating Abuse
One in 3 teens will experience dating abuse.

The Barwick/Ruscak Act in 2008 expands the definition of domestic violence to include victims in dating relationships.
The Batterer
Any socioeconomic class, race, age.
Usually very charming.
Is critical of partners.
Believes in rigid sex role stereotypes.
Is often extremely or pathologically jealous.
Is commonly a substance abuser (but substance abuse is not the cause).
Uses abuse to gain control over another.
Has unrealistic expectations.
Often is cruel to animals or children.
Destroys property.
Blames others for their behavior or problems.
Once we described the
Cycle of Violence
Tension Building
Violent Incident
Now we recognize that every relationship, every episode is different.
We call this the Campaign of Violence or Abuse
There is no set pattern of abuse
One incident of violence can be enough
Abuse is ongoing in order to achieve the batters goals
What about the children?
Domestic violence affects every member of the family. Children living in a violent home live in constant fear.
3 million children witness violence in
their home each year.
Families under stress produce children under stress.
(Ackerman and Pickering, 1989)
Children are affected by domestic violence at all ages from prenatal to adolescence, physically, developmentally, behaviorally and cognitively as well as emotionally and psychologically.
Effects last well into adulthood, often manifesting in a new generation of victims and batterers.
Eating and/or sleeping disorders
Mood related disorders such as depression and emotional neediness.
Children learn that violence is an acceptable way to solve problems.
Over compliance, clinginess, or withdrawal.
Aggressive acting out/destructive rages.
Detachment, avoidance, fantasy family life.
Somatic complaints.
Finger biting, restlessness, shaking, or stuttering.
School problems.
Suicidal ideation.
Poor Health
Effects of Domestic Violence on Children

“If that were me I’d just get out of there.”

“I would never let anyone treat me that way.”

“How many times is she going to ‘let’ this happen before she leaves?”

Have you ever thought about what it would take to start your life over again?
Before You Say...
Mom feels...

Kids feel...


Loves Conditionally
Favors one child
Remakes Family History
Undermines Mom
Says He’s the Victim
Says He’s a “New” Dad
The Beat Goes On…
When women leave, the abuser still works on controlling her.
The children are used as Pawns…
Most cases of Domestic Violence
are never reported to the police.
What can we do?
Intimate Partner Violence results in more than 18.5 million mental health care visits each year.

One in three female trauma patients is a victim of abuse.

Family violence accounts for at least 21,000 hospitalizations, 99,800 hospital days, 28,700 emergency department visits and 39,000 physician visits each year in the United States alone.
HealthCare Professionals Can Make a Difference
IPV is a criminal concern, not a health concern.

Domestic violence is the leading cause of injury to women—more than car accidents, muggings, and rapes combined.
The nursing assessment should always include the consideration of domestic violence, regardless of the chief presenting complaint.

Is the medical history as given inconsistent with injuries or complaints? Are there old injuries in various stages of healing? Are there complaints of insomnia, nightmares, inability to cope, or anxiety? Are any of the injuries consistent with sexual assault?
How the Healthcare Provider Can Help
Clinical Warning Signs

1. General Appearance: Increased anxiety, fatigue, flinching on touch, overweight, underweight, hypertensive, flat affect, depression, anxiety, fear, suicidal ideation, low self-esteem.
2. Any injury or Multiple injuries.
3. Skin: Burns, bruises or old healed scars.
4. Head: Decreased hearing from multiple blows, subdural hematomas, headaches.
5. Eyes: Swelling, detached retina.
6. Gastrointestinal: Non-ulcer dyspepsia, irritable bowel syndrome, globus.
7. Genital/urinary: Bruises, tenderness, recurrent vaginitis, vague pelvic pain, miscarriage, preterm labor, low birth weight delivery, rape, sexual assault.
8. Rectal: Bleeding, edema, irritation.
9. Musculoskeletal: Fractures, (especially facial, radius, ulna, ribs, shoulder dislocation), limited motion, old fractures, chronic pain, primary fibromyalgia.
Red Flags of Battering
1. Behavioral: Change in appointment pattern; multiple visits for vague complaints, or multiple missed appointments; frequent walk-ins or emergency room visits; patient can't be contacted at home; doesn't take medication as directed.
2. Past History: States history of child abuse; history of previous emotionally or physically abusive relationships.
3. Illness: Chronic pain (headache, pelvic pain, abdominal pain, irritable bowel); Gynecologic problems such as recurrent STD's, low birth weight deliveries, etc.; Depression, other stress-related symptoms.
4. Injury: Delay seeking care for injuries, minimizing injuries.
5. Pattern of Injury: Primarily central region: face with fractures, hematoma, lacerations around eyes, lips, perforated tympanic membrane; chest: breast injuries, broken ribs; abdomen and genital injuries. Old injuries or bruises in various stages of healing. Bites, burns, injury to a pregnant woman, especially to the abdomen. Recurrent minor trauma.
6. Psycho-social: Suicide attempts, alcoholism, substance abuse, low self-esteem.
Pregnant Women
are Safe...Right?!

Physical abuse during pregnancy can be dangerous to the health of the mother and her infant. It can cause miscarriages, still birth, low-birth weight and pre-term deliveries.

Abuse often starts or worsens during pregnancy. Women abused during pregnancy are more likely to seek health care for injuries than women abuseed before pregnancy.

Telling an abused pregnant woman that she has the right to live in peace may one day save her life as well as her baby's life.
The Examining Room When The Partner is Present:

How does the patient interact with his or her partner? What is the partner's behavior? What is the patient's affect, style of communicating, and finally what is the medical history given?

How does the partner act? Is the partner reluctant to leave the patient's side? Does the patient "flinch" when partner speaks? Does the partner answer for the patient? Watch facial expression, vocal inflection and body language for clues to the patient's emotional condition

There is no absolute method of predicting lethal behavior but experience has taught that past assailant behaviors are, when clustered, accurate predictors of danger. These include, but are not limited to, threats and fantasies about homicide and suicide, along with a history of attempts. Also, depression and situational stress, like job loss, is a predictor of lethal behavior, combined with other factors. Possessing and using weapons, being obsessed about the partner, making statements such as "I can't live without her", and isolation with a complete dependency on the victim are all predictors of dangerous behavior. Rage over any hint that the victim may leave, consuming alcohol or other drugs while furious or depressed and having ready access to the victim or stalking her after she has obtained a protective order are other dangerous signs.

If a victim discloses any of these behaviors by the partner, extraordinary measures should be taken to protect the victim and her children. These measures might include emergency transportation, and meticulous follow-up. The victim needs to be supported in any attempt she wishes to take to protect herself and health care professionals should contact the local domestic violence center for assistance with immediate safety planning for the victim.
When you are ready to pursue the source of injuries or problems, the patient must be in a secure, private environment, where no one can overhear her responses. If the partner refuses to leave, follow the protocols in place at the health care setting, including summoning security or others to assist in examining and interviewing the patient alone.

The health care professional must maintain a positive, supportive attitude: caring, objective, and accepting. Teaching may be a prominent part of the interaction, as many victims, particularly those with a long history of abuse, may not recognize the violence as abusive and criminal, as well as undeserved.
Important Questions to Ask

*Is anyone in your family hitting you?
*Has anyone ever hit you while you were pregnant?
*Have you ever received medical treatment for any abuse injuries?
*Can you mark on the body map where he hit you the last time he hurt you?
*Does your partner ever threaten you?
*Does your partner prevent you from leaving the house, from getting a job or
returning to school?
*What happens when you disagree with your partner?
*Does your partner destroy things you care about: family photos, your clothes,
hurt your pets?
*Are you forced to have sex when you're not feeling well, or do sexual things
you don't want to do?
*Do you have to have sex after a fight to "make up"?
*Does your partner watch you all the time? Call home frequently? Accuse you
of "coming on" to everyone?
*Do you know where to go or who could help you if you were abused?
*Some patients say they had an argument, then later say they were beaten. *Has this happened to you? Are you being beaten?
The Victim Acknowledges the Abuse

Create a supportive atmosphere so she can discuss her feelings. Inform her about any reports that need to be filed (police, child protective services, etc.). Acknowledge the danger and injustice of her situation. Let her know she is not at fault and that you are glad she has confided in you.

She has several options including immediate transport to a shelter, shelter information for a later date, returning to the partner after getting a follow-up appointment to return to the health care setting, or waiting for the police to file a report for visible injuries.

Teach her the signs of escalating physical danger, particularly access by the partner to weapons, threats he has made, and others. Most victims are acutely aware of the signs a partner sends of escalating violence.

Give her information about a protective order, and any other resources available in the community for her immediate protection and the protection of her children, as well as the domestic violence shelter.
“Are you afraid to go home?”

“Is the violence escalating?”

“Are there weapons present?”

“Do you have anywhere safe to go?”

“Do you want police intervention?”
Assess Safety
Remember The


1= Threats of abuse including use of a weapon

2= Slapping, pushing, no injuries and/or lasting pain

3= Punching, kicking, bruises, cuts and/or continuing pain

4= Beating up, severe contusions, burns, broken bones

5= Head injury, internal injury, permanent injury

6= Use of weapons; wound from weapon
For medical documentation to be properly admissible in court, health care professionals need to be prepared to testify that the records were made during the regular course of examination or interview, that they were made in accord with routinely followed procedures, and that they have been properly stored, and access limited to professional staff.

Expressing concern about patient's safety, understanding how difficult it is for her to make changes that are necessary, and reassuring her that she is not alone is all appropriate actions to take. Reaffirming that the violence is not her fault is very important since the batterer routinely blames her for all his behaviors. Remind her that only the abuser can stop the battering and that it is a conscious choice he has made. But do NOT attack the abuser as this leads to the victim defending the abuser and will shut down the conversation.

Finally, and emphatically state that no one deserves to be beaten and that there is no excuse for violence and that she and her children deserve peace and safety are very strong steps to take with the victim patient. Always remind the victim that there are options and resources available and that health care professionals are there to help her with access to them.
Basic Intervention Strategies
Validating, Naming, Listening, Educating
Differing definitions of abuse – Your definition may differ from that of the patient, and paying close attention to the way they describes their experiences is crucial.
You must determine if it is in the best interest of the patient to explain that some behaviors (such as emotional abuse) are considered domestic violence, even if the patient did not previously consider them as such.
Assessing clients
It is unreasonable for the to expect that a victim will leave their perpetrator solely because they disclosed the abuse, and the professional should respect the victim’s autonomy and allow them to make their own decisions regarding termination of the relationship.
The gateway to all services

Crisis Counseling
Screening for shelter services
Screening for outreach services
Support talk
Information and education
24/7 Crisis hotline
855-655-SAFE (7233)
Connecting Patients to SafeHouse
The leading provider of services to victims and survivors of domestic violence in Seminole County

Access to shelter services leads to a 60-70% reduction in incidence and severity of re-assault compared to women who did not access shelter.
Shelter services led to greater reduction in severe re-assault than did seeking court or law enforcement protection, or moving to a new location.
Security Code Gate Entry
Bullet Proof Windows
Security Doors
Security Cameras Outside And Down The Street
Safe Place For Children To Play
911 Emergency Phones
Knowledgeable Staff Works With Schools And Job Sites.
Staying Safe at SafeHouse
Individual, Group Counseling & Parenting classes
Injunctions for Protection (a.k.a. Restraining Orders)
Referrals to Seminole County Legal Aid
Community Mid Florida Legal Services referrals
Victims of Crime Compensation - Filing Assistance
Translation Services
Connection with Victim Witness Counselors
Court Support (Civil & Criminal proceedings)
While They are Here
Outreach and Legal Advocacy
Safety Plans Are Vital
Helping the Ones Who Abuse and
Holding Them Accountable
The main goal for treatment for offenders of domestic violence is to minimize the offender’s risk of future domestic violence, whether within the same relationship or a new one.

Batterer’s Intervention Programs
24-36 weeks
Maximum of 12 participants
Genders specific
Accountability should be the focal point not just anger management
Successful completion of treatment is generally associated with old age, higher levels of education, lower reported drug use, non-violent criminal histories, and longer intimate relationships.

Treatment of offenders involves more than the cessation of abusive behavior; it also requires a great deal of personal change and the construction of a self-image
Any corresponding problems should also be addressed as part of domestic violence offender treatment, such as problems with substance abuse or other mental illness.

Local BIP Services:
Families Against Abuse (FAA)
For men and women
3 locations
Sliding scale fee
Well documented, thorough medical records are essential for preventing further abuse.

Use patient's own words regarding injury or abuse
Legibly record all injuries; use a body map
Photograph injuries
Full transcript