Domestic Violence, Sexual Violence, Intimate Partner Violence

This course assists the healthcare worker in understanding domestic violence and the mandates about domestic violence that involve healthcare workers. It concludes with strategies for healthcare workers to use in identifying and managing victims of domestic violence.

After completing this course, the learner will be able to:

1. Define domestic abuse;
2. Recognize domestic violence trends seen across the United States;
3. Identify 5 risk factors for violence against a spouse or significant other;
4. Discuss 3 reasons why victims stay with the  abusive partners;
5. Explain 3 reasons why victims of domestic violence are not identified in the healthcare system; and
6. Create a treatment plan for a victim of domestic violence using the treatment protocol discussed in this activity.

Domestic violence amongst family members can take many forms. It may include emotional abuse, economic abuse, sexual abuse, threats, using the threat of removing children, using male privilege, intimidation, isolation, and other behaviors used to maintain fear, intimidation, and power. Acts of domestic violence are categorized into psychological battering, physical battering, or sexual abuse (CDC, 2010). The term domestic violence is still used, but more recently physical, psychological, or sexual violence in the context of a relationship is called intimate partner violence. The World Health Organization (WHO) defines intimate partner violence as “any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship” (Rhodes, 2012)

Psychological Battering causes trauma to the victim by acts, or threats of acts, or coercive behavior. Typical behaviors classified as psychological battering include controlling/dominating behavior, deprivation of economic, healthcare and physical resources, destruction of personal property, embarrassment, excessive possessiveness, harassment, humiliation, isolation from family and friends,  stalking, and verbal abuse, (CDC, 2010).

Physical Battering involves intentional physical attacks and aggressive behaviors that have the potential to cause harm, harm that ranges from bruising and pain to murder. It often begins with what is excused as trivial contact and escalates into more frequent and serious attacks (CDC, 2010).  

Sexual Abuse is typically divided into three categories: 1) sexual activity that is compelled, forced; 2) sexual activity with someone who cannot, or is incapable of giving consent or understanding the sexual situation, and; 3) sexual activity that is abusive, degrading, or humiliating (CDC 2010). Sexual abuse can take place in many types of relationships. Sexual abuse and sexual violence and violence against women commonly occur together in the context of a relationship of an intimate partner relationship.

Battering is a pattern of behavior that uses fear and intimidation to establish power and control over another person. It is an escalating process. It often begins with threats, name-calling[G2] , and damage to objects or pets. It may escalate into restraining, pushing, slapping, or pinching. Next, the behavior may include punching, kicking, biting, sexual assault, tripping, or throwing. Finally, battering may become life-threatening with serious behaviors like choking, breaking bones, or using weapons (CDC, 2010). Abuse tends to happen in cycles; does not just go away; and tends to get worse over time (CDC, 2010).

According to the Bureau of Justice Statistics, domestic violence accounts for approximately 17% of all violent crime in the United States (Planty, 2016). Most victims of domestic violence are spouses, but children and other family members are often victimized as well. The incidence of child physical abuse and child neglect associated with intimate partner violence has been estimated to be between 30%-60% (Lamers-Winkleman et al., 2012).

Although males are victims, females are the victim in 85% of abuse by a spouse or significant other (Planty, 2016). The lifetime risk for U.S. women of suffering from intimate partner violence has been estimated to be between 22% - 39% (Nelson et al., 2012). Elder abuse, child abuse, and same-sex abuse are also significant problems.

Fifty percent of domestic violence occurs at or near the victim’s home (US Census Bureau, 2013). Simple assault is the most common domestic violence offense, but domestic violence/intimate partner violence can be lethal: approximately 22% of homicides are domestic murders (Wozniak et al., 2010).

There is a strong association between substance abuse and domestic violence/intimate partner violence (Smith et al., 2012). Smith et al., 2012, found that almost 22% of all perpetrators of intimate partner violence had an alcohol abuse problem. About 31% of all the perpetrators had a substance abuse problem (alcohol, illicit drugs), and the use of alcohol in conjunction with incidents of intimate partner violence has been estimated to be between 22-60% (Smith et al., 2012; Taft et al., 2010).

The traditional image of domestic violence/intimate partner violence has been a man abusing a woman. However, women can be the perpetrators of violence in a relationship. There is controversy about how common women-initiated violence is. The reported incidence of abused men varies widely, but in 2010, Black et al. stated in the WHO reports that 1 in 4 men have been abused by their female partner, and this appears to be confirmed by other studies (Walter et al., 2016).

Research demonstrates that violence by women in the context of an intimate relationship is relatively common. But the consequences to the victims and the motives of the female perpetrator do appear to be different. The violence perpetrated by women seems to be less frequent, but any particular incident is likely to be more severe. Violence is also common in lesbian, gay, bi-sexual, and transgender relationships (Goldberg et al., 2012).

Abuse tends to occur in cycles. It does not just go away and tends to get worse over time. Domestic violence and intimate partner violence typically, but not always, follows a pattern. There is a period of tension building; there is an episode of violence; and there is a time calm, or a "honeymoon" (Hancock, 2012). Research suggests the more severe the violence, the more chronic it is and the more likely it is to worsen over time (Lipsky et al., 2012).

The cycle of violence is as follows:

1. Tension Building
   1. Tension mounts in the relationship.
   2. The batterer is irritable, frustrated, and unable to cope with everyday stresses.
   3. The victim attempts to appease the batterer by becoming compliant, nurturing, or staying out of the way
   4. The victim often assumes responsibility for controlling the abuser’s anger
   5. The victim denies the inevitability of the beating and the terror.
   6. The batterer fears that the victim will leave and their fears are reinforced by the victim’s coping strategy of withdrawing and avoiding.
2. The Battering Incident 
   1. The batterer's intent is to teach a lesson, not to inflict injury. In the process, they lose control of their rage
   2. Only the batterer can end this phase
   3. The victim needs a safe place during this phase
   4. Once over, the victim will deny the incident, injuries, and terror
3. The Calm Respite of "the Honeymoon."
   1. The batterer is kind and charming, afraid that the victim will leave
   2. The victim believes the suffering is over
   3. Then the cycle continues and returns to stage one

There are many theories as to why some people are abusers. However, the reason abusers use this behavior is that violence is an effective method for gaining and keeping control over another person. In a domestic situation, the abuser traditionally has not suffered adverse consequences as a result of violent behavior.

Historically, domestic violence in many cultures and societies has not been treated as a "real" crime. This lack of regard to violence is evident in the absence of severe consequences, like incarceration or financial penalties (WHO, 2016). Some cultures support the man’s right and just cause to punish their spouse by beating, in some circumstances (Waltermaurer, 2012; Uthman et al., 2011; WHO, 2016).

Abusers often display immaturity and are dependent and non-assertive (Saddock, 2015). They tend to suffer from strong feelings of inadequacy, and they use their bullying behavior to humiliate their partner in order to support their own low self-esteem. They sometimes displace aggression provoked by others onto their partner. The psychological dynamics of male abusers include identification with an aggressor (father, boss, brother, etc.), testing behaviors (i.e., “Will she stay with me no matter what I do to her?”), distorted desires to express manhood, and dehumanization of women (Saddock, 2015).

Risk factors for violence against their spouse or significant other are (Farrell, 2011; Theobald et al., 2012; WHO, 2016):

• Family history of violence
• Alcohol and drug use
• Emotional dependency, insecure and low self-esteem
• Lack of impulse control
• Antisocial, aggressive, and borderline personality disorders
• Poverty
• Marital discord or conflict

Research from both developed and undeveloped countries has consistently identified the following triggers for domestic violence (Dobash et al., 2011):

• Not obeying the man;
• Arguing back;
• Not having food ready on time;
• Not caring adequately for the children or home;
• Questioning the man about money or girlfriends;
• Going somewhere without the man’s permission;
• Refusing the man sex;
• The man is suspecting the woman of infidelity.

Batterers come from all social classes, races, cultures, religions, backgrounds, and countries (WHO, 2016). The following behaviors may be warning signs (Farrell, 2011; Theobald et al., 2012):

• Extreme jealousy;
• Blames others for their faults and circumstances for their problems;
• Unpredictable behavior;
• Verbally abusive;
• Unable to control their anger;
• Always asking for a second chance, saying they’ll change and won’t do it again;
• Their family resolves problems with violence;
• Plays on your guilt;
• Their way is the only way;
• Behavior often worsens when using alcohol or drugs; and
• Cruelty to animals.

There have been assessment tools developed that can help identify someone who has the potential for domestic violence/intimate partner violence. The Spousal Abuse Risk Assessment (SARA) is a validated tool that looks for the presence of 20 behaviors such as a history of assault and/or sexual violence, personality disorder, history of the use of weapons, and emotional denial or minimization of violence (Theobald et al., 2012).

Why do victims stay? All too often that question is answered with a victim-blaming attitude. Victims of abuse often hear that they must like or need abusive treatment, or else they would leave. Sometimes, victims are told that they “love too much" or have low self-esteem. The truth is that no one likes being beaten, regardless of his or her emotional state or self-image. The reasons that a victim stays are many and complex (Kelly, 2011; Panchanadeswaran et al., 2011; Employee Assistance, 2004).

1. Lack of resources
   1. Responsibility for dependent children.
   2. Not employed outside of the home.
   3. The victim does not solely own any property.
   4. Lack of access to cash or bank accounts.
   5. Fear of being charged with desertion; therefore, losing children or joint assets.
   6. Fear of a decline in living standards for herself and her children.
2. Institutional responses
   1. Clergy and secular counselors are often trained to see only the goal of saving the marriage at all costs.
   2. Police officers treat domestic violence as a dispute instead of a crime.
   3. Police may try to dissuade women from filing charges.
   4. Prosecutors are reluctant to prosecute cases and judges are lenient with the sentencing.
   5. Even with a restraining order, there is little to prevent a released abuser from returning and repeating the assault.
   6. There are not enough shelters to keep victims safe.
3. Traditional ideology
   1. The belief that divorce is not a viable alternative.
   2. The belief that a single parent family is unacceptable, and that even a violent father is better than no father at all.
   3. Many women are socialized to believe that they are responsible for making their marriage work.
   4. The isolation of a victim contributes to a sense that there is nowhere to turn.
   5. Rationalization of their abuser’s behavior by blaming stress, alcohol, problems at work unemployment, or other factors.
   6. Many women feel that their identity and worth are contingent upon getting and keeping a man.
   7. During the non-violent phases, the abuser may fulfill the woman’s dream of romantic love. She believes that he is basically good.

Millions of children witness intimate partner violence at home (Harding et al., 2013). The effect of this exposure has been compared to direct physical abuse of the child (Harding et al., 2013), and these children suffer from a wide range of emotional, physical, and psychological problems listed below (Lamers-Winkleman et al., 2012; Bauer et al., 2013; Nicklas et al., 2013).

• Attention deficit/hyperactivity disorder
• Anxiety
• Behavioral problems, e.g., aggression
• Depression
• Eating disorders
• Poor academic performance
• Low self-esteem
• Need for psychotropic medications
• Nightmares
• Physical health complaints
• Self-harming behaviors

Domestic violence/intimate partner violence is also strongly associated with a high incidence of child neglect and maltreatment (Nicklas et al., 2013). Evidence suggests that domestic violence increases the risk of child morbidity and mortality (WHO, 2016).

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines standards for healthcare organizations and monitors compliance with those standards. JCAHO mandates that hospitals must develop criteria to identify possible victims of abuse. The criteria must focus on observable evidence and not just on allegations. It must at least address physical assault; rape or other sexual molestation; domestic abuse; and abuse or neglect of elders and children. The criteria should be developed in a way to prevent any action or question that could create false memories of abuse in an individual (Burnett, 2011).

Staff must be trained to apply the criteria. They should question whether abuse might have occurred if a patient's story for his or her injury does not match the actual injury. A hospital must maintain a list of private and public community agencies that provide help for abuse victims. Staff must be able to make appropriate referrals for victims (Burnett, 2011).

For example, a child’s x-rays may show an unexplained broken bone. Staff should observe the behavior of the people who brought the child to the emergency room. Does the child cling to one parent and avoid the other? Staff members should question the child in a non-threatening manner, look for bruises on the body, and listen to explanations to see if there is a balance between the physical evidence and the story.

New York was the first state that requires hospitals to establish protocols to identify and treat domestic violence victims and make referrals to community services. California passed the first state law mandating protocols for hospitals and clinics to detect the presence of violence in the lives of patients.

California further required domestic violence training a part of the licensing and re-certification process for healthcare providers. Connecticut, Florida, Iowa, and Kentucky also require domestic violence training for re-licensure of physicians (Medscape Education, 2012).

WHO (2010) recommends the following actions:

• Governments and other donors should be encouraged to invest much more in research on violence by intimate partners over the next decade.
• Programs should place greater emphasis on enabling families, circles of friends and community groups, including religious communities, to deal with the problem of partner violence.
• Programs on partner violence should be integrated with other programs, such as those tackling youth violence, teenage pregnancies, substance abuse and other forms of family violence.
• Programs should focus more on the primary prevention of intimate partner violence.

Early identification and intervention with victims of domestic violence can help prevent injuries and save lives (Nelson et al., 2012; Decker et al., 2012). Many victims of domestic violence seek assistance in healthcare settings, often repeatedly, but are only treated for symptoms and injuries. Unfortunately, healthcare professionals often fail to identify victims. Missed cases of intimate partner violence may be due to the screening method: depending on the screening tool that is being used, the rate of detection has been reported to range from 9.2% to 30.5% (Sprague, Madden, Dosanjh, et al., 2012).

Missed cases may also be due to healthcare professionals simply not screening (Sprague, Madden, Simonuvic, et al., 2012), and many nurses are not prepared to provide care to a woman who is a victim of violence from her partner (Sundborg et al., 2012). There are many reasons nurses, physicians, and other healthcare professionals may not screen for intimate partner violence (Beynon et al., 2012).

• Lack of time
• Lack of training
• Lack of resources
• Language barriers
• Cultural barriers
• Emotional discomfort
• Behavior of the victim, e.g., uncooperative, unwilling to accept help

Mental health providers see victims of domestic violence for suicide attempts, anxiety, and depression. Practitioners who specialize in chronic pain, such as headaches or stomach disorders, also treat victims of abuse. Pediatricians who see abused children may also see abused women because child abuse and spousal abuse frequently co-exist (Harding et al., 2013).

Pregnancy may be a risk factor for battering. Approximately 1 in 12 women in North America who are pregnant experience some form of intimate partner violence (Kramer et al., 2012). Violence during pregnancy increases the incidence of morbidity and mortality. Specifically, victims of violence are more likely to deliver a pre-term or low-birth-weight infant (Kramer et al., 2012), it affects breastfeeding, and these victimized women are more prone to miscarriage, depression, alcohol and drug abuse, and forgoing prenatal care (Hellmuth et al., 2013).

Healthcare providers can help by screening for domestic violence, documenting abuse in the medical record, safeguarding evidence, providing medical advice, referrals, and safety planning, and showing empathy and compassion. Victims of domestic violence/intimate partner violence may not discuss the violence unless they are asked directly (Beynon et al., 2012; Morse et al., 2012). However, many victims of domestic violence/intimate partner violence will talk about the abuse if they are asked in a direct, caring, and non-judgmental manner (Decker et al., 2012).

Abuse victims need referrals to legal and social services. They may need help with finding temporary shelter, advice on how to keep safe should they return home, and affirmation that the abuse is not their fault (Burnett, 2011).

Screening questions should always be asked in a private room, away from the batterer and preceded by assurances of strict confidentiality. The spouse or partner should be separated from the patient if they demand to accompany the patient into the examining room (Hancock, 2011).

It is not the role of the healthcare provider to invoke or foster criminal justice intervention. Calling the police is not always in the best interest of a victim of domestic abuse. Some victims of domestic violence have learned to distrust the police or believe that law enforcement intervention will further endanger them. Immigrant victims may fear that calling the police will lead to deportation. Others are unwilling to use law enforcement intervention until a safety plan is in place.

Each victim should be informed of their legal options and encouraged to make their own choices (Burnett, 2011; Hancock, 2011). The requirements for reporting incidents of domestic violence/intimate partner violence - what must be reported, how it must be reported and to whom, and who is responsible for the reporting – vary from state to state (Family Violence Prevention Fund, 2010).

Treatment should follow these steps (Saddock, 2015):

• Identify patients who may be suffering from domestic violence
• Encourage him or her to talk about it
• Listen nonjudgmentally
• Validate their fears and concerns
• Document their complaints, symptoms, and injuries
• Assess the danger they are currently in
• Provide appropriate referral and support

The first step in treatment is identification of the victim. Many women who are victims of abuse will not voluntarily share this information; however, they will discuss if the provider asks the right question in a compassionate, non-judgmental manner. The healthcare provider might start by asking, “Because violence is common in many people’s lives, I ask every patient the same question. At any point, has your partner harmed or threatened you?” These conversations should always take place in a private setting when the patient is alone.

If the patient answers yes to this question, the healthcare provider should encourage her to talk about it. The healthcare provider should listen nonjudgmentally; this helps begin the healing process and provides information that will help with treatment planning. It is also very important for the healthcare worker to validate the victim's fears because they often think that others won’t believe them or will downplay their experiences. The healthcare provider might say, “You don’t deserve to be treated this way,” and “You are not to blame.”

The healthcare provider must document the patient’s complaints and symptoms. The complaint should be written using the patient’s own words when possible. Also, be sure to detail and describe injuries including their type, size, location, and number. If possible take color photographs and include those in the chart as well.

Next, assess the danger to your patient. Determine whether he or she is safe to leave the healthcare setting. Indicators of escalating danger include an increase in the frequency, duration, or severity of assaults, new threats of homicide or suicide by the partner, threats to children or other loved ones, and the presence or availability of a gun.

Finally, healthcare providers should offer the appropriate referral and support. Start by treating the victim’s injuries. If the victim is determined to be in imminent danger, refer him or her to stay with friends, family, or at a domestic violence shelter. If he or she is not in imminent danger, provide written information about community shelters and resources. Also, be sure to provide him or her with a toll-free domestic violence hotline number.

Domestic violence is a crime that causes severe health consequences. Healthcare professionals are mandated and obligated to identify and offer assistance to victims of domestic violence. Legal and societal changes in the United States have reduced the occurrence of Domestic Violence, but the problem is still epidemic. Your efforts can make a difference.

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