Domestic Violence, a Significant Public Health Problem

Course Content

Author: Adrianne E. Avillion, D.Ed., RN

Contact Hours: 5

Categorize the various types of domestic violence.
Appraise the incidence and prevalence of domestic violence in the U.S.
Compare risk factors and protective factors relating to domestic violence.
Explain the impact of domestic violence.
Analyze barriers to reporting domestic violence.
Explain how to recognize victims of domestic violence.
Identify the requirements for reporting domestic violence.
Summarize the interventions to be taken when domestic violence is suspected.
Evaluate interventions for the prevention of domestic violence.

Introduction

An estimated 10 million adults experience domestic violence annually in the United States (U.S.) (National Coalition Against Domestic Violence [NCADV], 2020). At least one in seven children has experienced child abuse or neglect in the past year in the U.S. (Centers for Disease Control and Prevention [CDC], 2022b).

Domestic violence is found in every community and affects all people regardless of their age, gender, gender identity, race, religion, nationality, sexual orientation, or socioeconomic status. Its impact on victims and society in general is enormous (NCADV, 2020). This program categorizes the various types of domestic violence, how to recognize it, how to report it, and how to intervene when domestic violence is suspected.

Categorization of the Various Types of Domestic Violence

It is imperative that nurses and other healthcare professional be able to recognize and categorize the various types of domestic violence. In order to combat the increasing incidents of domestic violence healthcare professionals must not only recognize the different types of domestic violence but be able to use this recognition to provide the best possible care needed by victims of domestic violence. This care, in part, depends upon the ability of healthcare professionals to differentiate the various types of violence.

Domestic violence can be defined as “violence that takes place within a household and can be between any two people within that household ”(Moorer, 2021). For example, it can occur between a parent and child, intimate partners, siblings, or roommates. The term domestic violence is often used interchangeably with the term intimate partner violence (IPV) (also referred to as intimate partner domestic violence (IPDV). This interchangeable use is not accurate. Domestic violence occurs between any two people within a household, while IPV is a form of domestic violence that occurs only between romantic partners who may or may not be living within the same household (Moorer, 2021).

The following subcategories of abuse violence are those that are most often included under the category of domestic violence (Arizona Coalition, 2023; U.S. Department of Justice, 2022; Videbeck, 2020; Washington State Department of Social and Health Services, n.d.). It is imperative that all healthcare professionals recognize the various types of abuse that affect the patients under their care.

Physical Abuse: Physical abuse is a physical hostile injury or threatening physical hostile injury.
Sexual Abuse: Sexual abuse is forcing, or attempting to force, any sexual contact or behavior without consent. This includes actions such as forcing victims to look at pornographic materials or taking photographs of victims related to sexual activity.
Emotional Abuse: Emotional abuse involves undercutting someone’s self-esteem and sense of self-worth.
Economic Abuse: Economic abuse involves controlling or limiting someone’s ability to acquire, use, or maintain economic resources to which they are entitled.
Stalking: Stalking occurs when there is reasonable reason to fear for personal safety or fear for the safety of the family.
Neglect: Neglect as a form of abuse is the malicious, deliberate withholding of life necessities such as shelter, medication, or food.
Abandonment: Abandonment takes place when a vulnerable person is left without the ability to obtain life’s necessities including shelter, food, medical care, and clothing. For example,

Violence Alert! Specific Forms of Abuse

Child abuse, older adult abuse, teen dating violence, and IPV are specific forms of domestic violence. All forms of domestic abuse are affected by the preceding types of abuse violence. There are, however, some types of abuse and violence that impact certain groups of people more than others. This program addresses these differences and how they are part of the dynamics of domestic violence.

Incidence and Prevalence Appraisal

According to the National Coalition Against Domestic Violence (2020), more than 10 million adults are victims of domestic violence every year. This means that if each of these adults had to deal with only one occurrence of violence, an adult in the U.S. would undergo an episode of violence every three seconds. However, domestic violence typically occurs as a pattern of abuse resulting in repeated acts of abuse. Therefore, it is likely that an act of abuse occurs more frequently than every three seconds.

The extent of domestic violence may not be fully appreciated by healthcare professionals. As undergraduates or beginning practitioners, the emphasis may have been on the basics of dealing with victims of domestic violence without comprehending the actual extent of the problem.

Statistics that further emphasize how often domestic violence occurs include (NCADV, 2020):

About one in five female victims and one in 20 male victims need medical care because of their injuries.
One in five female victims and one in nine male victims need legal services.
About 23% of women and 14% of men have had to deal with severe physical violence committed by and intimate partner during their lifetimes.
On a typical day, domestic violence hotlines in the U.S. receive over 19,000 calls.
IPV is typically most common against women between the ages of 18-24.

Child Abuse Data

The CDC (2022b) defines child abuse as all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (e.g., teacher, coach, religious leader) that results in harm, the potential for harm, or threat of harm to a child. At least one in seven children have experienced child abuse or neglect in the past year in the U.S. This is probably an underestimate because many cases of child abuse go unreported (CDC, 2021b).

Older Adult Abuse Data

A serious problem in the U.S., older adult abuse is quite common. An older adult is defined as someone 60 years of age and older. An estimated one in 10 people, 60 years of age and older who live at home, experience older adult abuse. This number is likely higher because many older adult abuse victims do not report being abused (CDC, 2021b).

Marital Rape

In romantic relationships and marriage forced sex is sexual violence and is often referred to as marital rape. It is never the fault of the victim. Rape is defined as forcing another person into unwanted sexual intercourse and is sexual assault even if perpetrated by a romantic partner or spouse. Approximately nine percent of women and 0.5% of men have been victims of rape by an intimate partner (Casabianca & Russell, 2021).

Violence Alert! Marital rape is defined as a form of sexual assault committed by one spouse towards the other. Although most victims of marital rape are women, both men and women can become victims of this type of violence. Sociocultural and political ideologies significantly influence the way marital rape is viewed. Compared to other types of rape, marital rape is often viewed as not “real rape,” a marital “right,” and/or non-criminal in nature. Most nations, from the 20th century onward, have passed laws that criminalize marital rape. However, such criminalization does not guarantee that these laws are enforced or that victims feel comfortable reporting marital rape. Lack of knowledge about marital rape contributes to a lack of adequate patient care services to its victims (Banerjee & Rao, 2022).

Teen Dating Violence

Teen dating violence (TDV), also referred to as dating violence, affects millions of people in the U.S. It is a form of IPV and can take place in person, online, or via social media. About one in 12 U.S. high school students experience physical dating violence. About one in 12 high school students experience sexual dating violence. Students who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) experience higher rates of physical and sexual violence compared to students who identify as heterosexual (CDC, 2023).

Lethality

Homicide is prevalent among persons who experience domestic violence. Much of the research data about domestic violence homicide has been conducted on persons who experienced IPV. If an abuser has access to a firearm, the risk of IPV homicide increases by 400%. It is estimated that more than three women and one man are murdered by their intimate partners every day (NCADV, 2020). Between 70% to 80% of IPV homicides, no matter which partner was killed, a male physically abused the female before the murder (Shelter House, n.d.).

Research indicates that one in two female murder victims and one in 13 male murder victims are murdered by intimate partners. About 65% of all murder-suicides are committed by intimate partners, and 96% of murder-suicide victims are female (NCADV, 2020).

The U.S. has one of the worst records among industrialized nations for child lethality. An average of five children die every day due to child abuse and neglect. In 2019, U.S. state agencies found over 656,000 victims of child maltreatment. Sadly, research indicates that this number is far less than the actual number of child fatalities by as much as 50% or more (Child Help, n.d.).

From 2002 to 2016, the rate of non-fatal assaults on older adults increased by more than 75% among men. From 2007-2016, the rate of non-fatal assaults increased by more than 35% among women. The estimated homicide rate for men increased by seven percent from 2010 to 2016. Compared to non-Hispanic Whites, non-Hispanic Black or African American persons, non-Hispanic American Indian/Alaskan Natives, and Hispanic or Latino persons have higher homicide rates (CDC, 2021b).

Overall firearm-specific older adult homicide rates increased between 2014 and 2017. Of the 6188 victims, 62% were male. The perpetrator was an intimate partner in 39% of firearm homicides and 12% of non-firearm homicides. Common contexts of firearm homicides were familial/intimate partner problems, robbery/burglary, argument, and illness-related (e.g., the homicide was perpetrated to end the suffering of an ill victim, both victim and perpetrator had an illness, or the perpetrator had a mental illness) (CDC, 2021b).

Comparison of Risk and Protective Factors

Risk factors are characteristics that increase the likelihood of someone becoming a victim of abuse as well as the likelihood of becoming an abuser. Protective factors are characteristics that lessen the likelihood of abuse occurring (CDC, 2022a). It is important for healthcare professionals to become familiar with these types of factors to help predict persons at risk of becoming victims or abusers.

As healthcare professionals advance in their careers, they must take responsibility for not only their personal knowledge of risk and protective factors but responsibility for helping to educate their colleagues and their communities.

Individual Risk Factors

Children are at higher risk if they are younger than four years of age. They are also at higher risk if they have special needs such as physical disabilities, mental health issues, and chronic physical illness (CDC, 2022a).

Family Risk Factors

Children are at higher risk for being abused if their families (CDC, 2022a);

Have household members in jail or in prison.
Are isolated from, and not connected to, other people such as family, friends, and neighbors.
Experience other types of violence such as IPV.
Have high conflict and negative communication styles.

Community Risk Factors

Children are at higher risk for being abused if they live in communities with (CDC, 2022a):

High rates of crime and violence.
High rates of poverty and limited educational and economic opportunities.
High unemployment rates.
With easy access to drugs and alcohol.
Where there is low community involvement with residents.
Where neighbors do not know or look out for each other.
With few community activities for young people.
With unstable housing and where residents frequently move.
Where families frequently experience food insecurity.

Protective factors have been shown to lessen the likelihood of abuse and neglect. For children, these factors include individual, family, and community characteristics.

Individual Protective Factors

Individual protective factors include caregivers who (CDC, 2022a):

Create safe, positive relationships with children.
Practice nurturing parenting skills and provide emotional support.
Can meet basic needs of food, shelter, education, and health services.
Have a college degree or higher and have steady employment.

Family Protective Factors

Families are protective when they demonstrate (CDC, 2022a):

Strong social support networks and stable, positive relationships with people around them
Interest and being present in the life of the child.
Enforcement of household rules and engage in children monitoring.
Promoting relationships with caring adults outside the family who can serve as role models or mentors.

Community Protective Factors

Communities that qualify as “protective” are those where there (CDC, 2022a):

Is access to safe, stable housing
Is access to high-quality preschool.
Is access to nurturing and safe childcare.
Is access to safe, engaging after-school programs and activities.
Is access to medical care including mental health services.
Is access to economic and financial assistance.
Are work opportunities with family-friendly policies.

Healthcare professionals need to expand their knowledge of both risk and protective factors. As part of assessment and preventive efforts, they must work with families and community leaders to improve the environments in which children are born and raised.

Abuse of older adults is predicted to increase as many countries throughout the world have rapidly aging populations. In fact, it is estimated that the population of older adults will more than double from 900 million in 2015 to about two billion in 2050 (World Health Organization [WHO], 2022).

Abuse of older adults (defined as over the age of 60) can occur in a variety of locations, including the older adult’s home, the home of a family member or friend, or a long-term care facility. Persons more likely to experience older adult abuse are those who have no family or friends nearby and people with disabilities. Also at risk are adults who depend on other people for activities of daily living such as bathing and dressing. Vulnerable adults are often perceived as “easy targets” for abuse (National Institute on Aging, n.d.).

Additional risk factors for abuse include poor physical health, cognitive impairment, mental health illness, and low income. Persons who are in interpersonal relationships with the older adult (e.g., intimate partner, spouse, child) may also be a risk factor. If there is a history of abusive behavior (whether committed by the older adult or a family member) within these relationships, the risk of older adult abuse increases. Cultural norms (e.g., ageism, and normalization of violence) can also contribute to an elevated risk of abuse (WHO, 2022).

There are also specific risk factors pertaining to older adults who live in long-term care facilities. These factors increase the risk of abuse of older adults and also increase the risk of the staff of long-term care facilities becoming abusers. These include (CDC, 2020):

Inadequate staffing.
Lack of qualified staff members.
Stressful working conditions.

Protective factors for older adult abuse have not been studied as extensively as risk factors. However, some protective factors have been identified. These include having social and community support. This means having the support of family and friends and living in communities where residents feel connected to each other and are involved in the community (CDC, 2020).

Risk and Protective Factors for Teen Dating Violence

Research suggests that the frequency and severity of TDV increases with age. Further compounding the likelihood of TDV is that some teens often believe that some behaviors, such as teasing and name-calling are a “normal” part of a relationship. These behaviors, however, can become abusive and progress to more serious forms of violence. (CDC, 2023).

Female teens typically experience higher rates of physical and sexual dating violence than male teens. Members of the LGBTQ community, or those who are unsure of their gender identity are also more likely to experience TDV compared to teens who identify as heterosexual (CDC, 2023).

Teens who experience stressful life events or show signs and symptoms of trauma such as a history of sexual abuse are at increased risk. Living in poverty, coming from disadvantaged homes, and witnessing violence in the home, neighborhood, or community are also risk factors. Living in environments that cultivate beliefs that violence is acceptable puts teens in circumstances where they may learn that violence, particularly violence against women, is both normal and acceptable (Youth.gov, n.d.).

Teens are greatly influenced by their peers. If they have friends who are involved in a violent relationship, they may start to see this type of relationship as normal. Having friends who display violent behaviors increases the risk. Teens who have been exposed to harsh parenting such as inconsistent discipline, lack of supervision, or lack of affection are more likely to become involved in a violent relationship. Personal characteristics that increase the risk of being the victim of TDV include having low self-esteem, anger issues, depression, and/or maladaptive or antisocial behaviors (Youth.gov., n.d.).

TDV cannot be addressed without addressing family violence in the home. Research indicates that children who are exposed to IPV and/or child maltreatment are more likely to become involved in IPV throughout their adolescent years and adulthood as victims, perpetrators, or both. (Children’s Hospital of Philadelphia Center for Violence Prevention [CHOP], 2020).

CHOP’s STOP Intimate Partner Violence program has a screening program that offers support for IPV screening by healthcare professionals in order to identify families experiencing domestic violence and intervene to interrupt such violence. Such screening programs facilitate intervention to minimize the adverse effects of childhood IPV exposure (CHOP, 2020).

It is important to have objective, honest discussions with teens are important. These kinds of discussions can help teens develop positive relationship-building skills, minimize risk factors for TDV, and decrease the risk of teens becoming violent perpetrators. Research also suggests that school-based programs can improve problem-solving and address dating violence prevention in conjunction with the prevention of other high-risk teen behaviors such as substance use and risky sexual behaviors (CHOP, 2020).

It is a matter of grave concern that young adults, parents, and educators have little or no awareness of the problem of TDV. Research suggests that 81% of parents are unaware that dating violence is a problem, and only 33% of teens in a violent relationship tell someone about the abuse (CHOP, 2020).

Dating violence that takes place via technology increases the covert nature of TDV. A survey of 7-12th grade students in the states of New York, Pennsylvania, and New Jersey found that over 25% of teens in a relationship had experienced some type of cyber dating abuse victimization in the prior year. The results also showed a link between cyber dating abuse and other forms of dating violence. In 2013, Pennsylvania Senate Bill 1116 was passed to amend the Public-School Code. It was enacted to ensure that schools take the following measures to prevent IVP (CHOP, 2020).

Have a policy on dating violence.
Train school faculty on dating violence.
Educate students in grades seven through 12 about dating violence.

Partner with local domestic violence and rape crisis programs to develop materials, resources, and responses that are best suited to the unique needs of teen victims.

Violence Alert! Teen Dating Violence Prevention

One of the reasons it is so important that schools become involved in preventing TDV is that about 50% of teens who experience physical abuse from a dating partner are abused on school premises. Research also indicates that implementing prevention strategies in junior high, and high school, and via Public School Code are effective strategies in deterring attitudes and behaviors that lead to IVP (CHOP, 2020).

Risk and Protective Factors for Intimate Partner Violence

The majority of research regarding risk and protective factors focuses on risk factors for becoming a perpetrator of IPV. Specific risk factors for IPV victims are closely related to abuser characteristics. There are some general risk factors that increase the risk of becoming a victim of IPV. These include (American College of Obstetricians and Gynecologists (ACOG), 2022; Shelter House, n.d.):

Being female.
Being a member of the LGBTQ community.
Being pregnant.
Being a member of a culture or community that views domestic violence as “normal.”
Being isolated from family or friends.
Lack of community interaction and support.
Having a disability or physical or mental health illnesses.

Protective factors include being part of a supportive community, having a support network of family and friends, and being part of a family, community, and culture that opposes violence (ACOG, 2022; CDC, 2021a).

Violence Alert! IPV and Pregnancy

Research findings suggest that between 3%-9% of pregnant women experience IPV during pregnancy. Experts recommend that all females who are pregnant be screened and monitored for domestic violence (Ramaswamy et al., 2019).

Risk and Protective Factors for Domestic Violence Perpetration

There are a number of risk factors associated to a greater likelihood of domestic violence. However, these factors may contribute to perpetrator development, but might not necessarily be the direct cause. A combination of individual, relational, community, and societal risk factors are linked to the risk of becoming a perpetrator (CDC, 2021a).

Individual Risk Factors

Stress is a major risk factor. Examples of stress factors include economic stress and relationship stress. Persons with low self-esteem, low education, and low income are more susceptible to becoming perpetrators (CDC, 2021a; Washington Coalition of Sexual Assault Programs (q WCSAP), n.d.).

At-risk persons display anger and hostility and a history of aggressive or delinquent behaviors as a youth. They have poor behavioral control and impulsiveness. Becoming a perpetrator is facilitated if someone excessively uses alcohol and drugs. Mental health issues that increase risk include depression, suicide attempts, and antisocial personality traits (e.g., disregard for normal social behavior, lack of concern for other people’s distress, and difficulty sustaining long-term relationships) (CDC, 2021a).

Additional risk factors include (CDC, 2021a):

Lack of non-violent social problem-solving skills.
History of being physically abusive.
Having few friends.
Being isolated from other people.
Being emotionally dependent and insecure.
Belief in strict gender roles (e.g., male dominance in relationships).
Hostility of men toward women.
Desire for power and control in relationships.
History of physical or emotional abuse in childhood.

Relationship Factors

Relationship conflicts such as jealousy, possessiveness, tension, divorce, or separations.
Dominance and control of relationships by one partner over the other.
Families that are experiencing economic stress.
Unhealthy family relationships and interactions.
Association with antisocial and aggressive peers.
Parents with less than a high school education.
Witnessing violence between parents as a child.
History of experiencing poor parenting as a child.
History of experiencing physical discipline as a child.

Community Factors

High rates of poverty and limited educational and economic opportunities.
High unemployment rates.
High rates of violence and crime.
Neighbors do not know or look out for each other.
No community involvement among residents.
Easy access to drugs and alcohol.
Weak community sanctions against domestic violence (e.g., neighbors are unwilling to intervene when they witness violence).

Societal Factors

“Traditional” gender norms and gender inequality (e.g., women should stay at home and not work, be submissive to males, men should support the family and make the decisions).
Cultural norms that support aggression toward others.
Societal income inequality.
Weak educational, economic, social, and health policies or laws.

Violence Alert! Why Do People Become Stalkers?

Research suggests that 50% of one sample of stalkers had a mental health disorder such as antisocial personality disorder, narcissistic personality disorder, or borderline personality disorder, which is especially prominent in women stalkers. Stalking victims are both male and female. Three times more women than men are victims of stalking, but half of male victims of stalking report having female stalkers (Psychology Today, n.d.).

Protective Factors

Persons who have strong social support networks and stable, positive relationships with others are less likely to become abusers. A stable, happy home life that denounces violence during childhood is also quite protective (CDC, 2021a).

Communities where residents feel safe and connected to each other are protective. Additional characteristics of protective communities include adequate coordination of resources and services among community agencies, access to suitable housing, access to medical care and mental health services, and access to employment and educational opportunities with financial help as needed (CDC, 2021a).

Critical Thinking Scenario # 1

Max is a 14-year-old male who is growing up in a single-parent household. His mother has a history of drug and alcohol abuse and does not live with Max, his siblings, and his father. She was recently imprisoned because of her involvement in selling illegal drugs. Max’s father works long hours to support the family and is a firm but fair disciplinarian. Max’s grandmother lives with the family to help with the children and the household tasks. She is close to her grandchildren.

Max’s neighborhood has high rates of poverty and few employment opportunities. His neighbors, however, are friendly and supportive of each other. Several of Max’s friends display aggressive behaviors.

Max wants to attend college and hopes to eventually study law. He devotes much of his time to his studies. His friends often ridicule his determination to earn good grades.

Angela is a 22-year-old senior at an Ivy League university. She is a business major and her parents assume she will attend graduate school and eventually become part of her family’s large business conglomerate. Angela’s family belongs to the upper socioeconomic class and has a wealthy lifestyle. Her parents travel frequently and have done so throughout Angela’s childhood. When her parents were away, Angela was taken care of by a nanny. Angela’s parents argued frequently and Angela witnessed many verbally aggressive conflicts.

Angela has never been enthusiastic about being part of the family business. Her desired career goal had always been to study marine biology, and she read everything she could about the subject throughout her childhood. When she told her parents about her dreams, they laughed and insisted that her life was to be spent as a businesswoman. Their constant criticism and threats to stop supporting her financially (or let her live at home) as soon as she turned 18 resulted in Angela doing as they wished. She was afraid that without her parents’ approval and financial support, she would not be able to live.

Angela’s self-esteem plummeted, and she began to use alcohol to forget about her unhappiness. She begins to date a fellow business major, Jason, who flatters her and asks many questions about her family and their business activities. Jason seems especially interested in her family’s financial status. Angela is reluctant to talk about these topics, making Jason angry. The more reluctant she is to answer his questions the angrier he becomes. He begins to display aggressive behaviors and tells her that if she wants to continue dating him, she has better start answering his questions.

Both Max and Angela face problems that can impact their susceptibility to abuse. Consider the following questions.

What factors might make Max susceptible to becoming an abuser?
What are the protective factors that decrease Max’s likelihood of becoming an abuser?
What factors might make Angela susceptible to being abused?
What are the protective factors that decrease Angela’s likelihood of being abused?

Max’s circumstances involve both risk and protective factors. Max has a parent in jail who has a history of using alcohol and illegal drugs and selling them as well. Seeing a parent abusing drugs and having a parent in jail contributes to an environment of unhealthy family relationships and interactions. Max’s father works long hours to provide for the family. This suggests economic stress. Max lives in a neighborhood that has high rates of poverty and few employment opportunities. Some of his friends display aggressive behaviors. These friends ridicule Max’s study habits. Since peer acceptance is very important to adolescents, Max may adopt similar behaviors to “fit in.”

Fortunately, Max’s circumstances also involve several protective factors as well. His father is described as a firm but fair disciplinarian, indicating consistent parenting. His grandmother lives with the family and is close to her grandchildren. This most likely helps to establish a positive environment.

Max’s neighbors are described as friendly and supportive, which is part of the protective factors needed to decrease the risk of becoming an abuser. He has specific career goals and is working hard to achieve them. If Max is able to withstand peer pressure (a considerable risk factor), it is probable that he will not develop abusive tendencies.

Angela’s circumstances make her vulnerable to abusive relationships. During her childhood, Angela’s parents were often away from home on extended travels. When they were at home they argued frequently, often in front of Angela. Witnessing verbal aggression and the lack of positive parental involvement are risk factors for experiencing abuse.

Her parents pressured her to pursue a career in which she had no interest. They demand that she join the family business after she completes her education. They have used their considerable financial assets to her disadvantage. If Angela had not agreed to their demands, they would have threatened to stop supporting her financially, including providing her with a home, as soon as she turned 18. These threats, compounded by their constant criticism, drastically affected Angela’s self-esteem and sense of self-worth. She turns to alcohol as a means of forgetting her unhappiness. These circumstances increase Angela’s vulnerability.

Angela’s dating situation is also a risk factor for becoming a victim of abuse. Her new boyfriend is unusually interested in her family’s financial status. When she is reluctant to talk about it, Jason becomes angry and aggressive. Her boyfriend’s displays of aggression are warning signs of a severely dysfunctional relationship. This situation is not indicative of a healthy interpersonal relationship.

Despite the risk factors in Max’s environment, he has protective factors that support his future goals. Angela’s risk factors are not counteracted by protective factors, increasing her vulnerability to becoming involved in abusive relationships.

Impact of Domestic Violence

Domestic violence can have many effects on the mind, body, and psyche. It is important that families and individuals affected by domestic violence acknowledge these effects as a critical first step in the healing process (Arizona Coalition, n.d.). Healthcare professionals are responsible for not only knowing about the impact but also for explaining the impact to colleagues, victims, and the community.

Although people may experience similar types of abuse, their responses to such trauma often vary from person to person. Factors that may influence how someone deals with the impact of abuse include (Arizona Coalition, n.d.):

Frequency of abusive attacks.
Severity of the abuse.
How someone deals with stress.
Age at which the abuse occurred.
Exposure to trauma unrelated to the abuse.
How quickly someone obtains therapy or other interventions.

The American Psychological Association (APA) (2022) defines trauma as “an emotional response to a terrible event like an accident, rape, or natural disaster. Immediately after the event, shock, and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships, and even physical symptoms like headaches or nausea.”

Impact of Emotional Abuse

All types of abuse can cause long-term detrimental effects. However, some healthcare professionals, as well as the general public, may attempt to “rank” the severity of abuse based on the type of abuse committed. For example, some people, including some healthcare professionals, may believe that physical abuse is “worse” than emotional abuse. Researchers recently conducted a study based on the hypothesis that those “who report emotional abuse will have higher scores for depression, anxiety, stress, and neuroticism personality compared to those who reported only physical, only sexual, or combined physical and sexual abuse” (Dye, 2020).

Seven hundred college students participated in an online survey. Analysis of the results supported the hypothesis. This, and previous studies, indicated that emotional abuse may be the most damaging form of abuse causing adverse developmental consequences in children and higher scores for depression, anxiety, stress, and neuroticism (the degree to which someone experiences the world as stressful, threatening, and dangerous). The researchers advocate for public awareness campaigns to raise “public and community awareness and evidenced-based treatments that help with the psychological consequences of emotional abuse (Dye, 2020).

Healthcare professionals must apply research findings to their professional practice. They should be aware of the impact of emotional abuse and screen patients for the effects of such abuse. Victims of emotional abuse may be overlooked because it produces no observable physical effects. Research findings such as these show the importance of screening for, and implementing effective interventions for victims of emotional abuse.

Survivors of emotional abuse may experience both short and long-term adverse effects. Short-term effects include isolation, loneliness, self-doubt, shame, low self-esteem, confusion, fear of interacting with other people and avoiding circumstances related to the abuse. Long-term effects include mental health disorders, anger, chronic stress, emotional apathy, and difficulty forming interpersonal relationships (Telloian, 2022).

Impact on Children

Children who deal with emotional abuse may have effects specific to their age. “Acting out” and displaying signs of attention deficit hyperactivity disorder (ADHD) such as squirming or fidgeting, having problems getting along with others, inattention, lack of focus, and making careless mistakes in school” (Telloian, 2022).

Children who have been victims of emotional abuse may have trouble managing how they respond to emotions that are challenging. They may be less emotionally mature than their peers, and they may find it difficult to develop trusting relationships (Telloian, 2022).

Research findings suggest that the experience of childhood emotional abuse can lead to poor coping skills. Examples include emotional disconnect, fantasizing, or imagining to the extent that they develop avoidant behaviors and a tendency to isolation (Telloian, 2022).

Impact of Domestic Violence on Mental Health

Domestic violence can severely impact the mental health of its victims. Mental health stability may be compromised and can lead to a range of problems. The following disorders have been linked to domestic violence.

Violence Alert! The Link Between Mental Health and Domestic Violence

Research indicates that women experiencing domestic abuse are more likely to experience mental health disorders. Conversely, women with mental health disorders are more likely to be domestically abused (Mental Health Foundation, 2022).

Post Traumatic Stress Disorder

Post traumatic stress disorder occurs when someone experiences or witnesses a natural disaster, combat, assault, or other type of significant physical or emotional trauma. Symptoms typically appear three or more months after the traumatic event. The onset of symptoms can be delayed not only for months but for years as well. PTSD is often chronic (Videbeck, 2020). Research shows that the occurrence of PTSD among victims of IPV can range from 31% to 84% (Kahawita, 2022).

Symptoms vary in intensity and can differ from person to person. They are typically grouped according to the following classifications (Mayo Clinic, 2022b).

Intrusive Memories. Intrusive memories include:

Recurrent unwanted memories of the traumatic event that cause distress.
Flashbacks, which involve reliving the traumatic event as if it were happening again.
Dreams or nightmares about the traumatic event.
Physical reactions and severe emotional distress.

Avoidance. Symptoms of avoidance include:

Avoiding or trying to avoid thinking or talking about the event.
Avoiding or trying to avoid places, activities, or people that cause remembrance of the traumatic event.

Negative Changes in Thinking and Mood

Symptoms of negative changes include:

Negative thoughts about themselves, other people, or the world in general.
Hopelessness.
Memory problems, including trouble remembering details of the traumatic event.
Problems maintaining interpersonal relationships.
Lack of interest in interacting with family and friends and in participating once enjoyable activities.
Feeling emotionally detached and numb.

Changes in Physical and Emotional Reactions. Also referred to as “arousal,” these symptoms include:

Startles easily or is easily frightened.
Constantly being alert to the possibility of danger.
Risky behaviors such as taking excessive amounts of alcohol or driving recklessly.
Trouble sleeping.
Difficulty concentrating.
Anger, irritability, and/or aggressive behavior.
Overwhelming guilt.
Excessive feelings of shame.

Violence Alert! Symptoms in Children

In children six years of age and older signs and symptoms may also include reenacting the traumatic event as part of playing and/or having dreams that may or may not include specifics about the traumatic event (Mayo Clinic, 2022b).

Depression

Depression (also referred to as major depressive disorder or clinical depression) is a mood disorder characterized by ongoing feelings of sadness and loss of interest in the activities of life. Depression affects how someone feels, thinks, and behaves. The ability to perform day-to-day activities may be compromised and interpersonal relationships damaged (Mayo Clinic, 2022a; Videbeck, 2020

Symptoms typically occur most of the day, almost every day, and may include (Mayo Clinic, 2022a):

Feelings of sadness, hopelessness, worthlessness, and/or fixating on past failures.
Irritability, frustration, and angry outbursts.
Loss of interest in most or even all normal activities.
Lack of energy and excessive fatigue.
Sleep disturbances such as sleeping too much or too little.
Agitation and anxiety.
Trouble concentrating, making decisions, and memory problems.
Physical symptoms such as headaches, gastrointestinal problems, and back pain.
Frequent thoughts of death by suicide.

Violence Alert! Depression Symptoms in Children, Teens, and Older Adults

In children, symptoms may also include clinginess, worry, aches and pains, being underweight, and/or refusing to go to school. In teens, symptoms may also include feelings of worthlessness, negativity, poor school attendance, poor grades in school, feeling misunderstood, using recreational drugs and alcohol, and withdrawing social interaction. Older adults may also exhibit personality changes, changes in memory, loss of appetite, loss of interest in sex, and suicidal ideation (Mayo Clinic, 2022a).

Generalized Anxiety Disorder (GAD)

Generalized anxiety disorder (GAD) is characterized by feelings of fear, worry, and being overwhelmed at least 50% of the time for six months or more. Affected persons are unable to control these feelings. They are consumed by excessive, ongoing, and unrealistic worry (Cleveland Clinic, 2022; Videbeck, 2020).

Children who experience or witness domestic violence are also vulnerable to the development of GAD. Children with this disorder frequently worry about the same things as children who are not affected by an anxiety disorder. However, the difference is that for the children with GAD, the worry is constant and interferes with their ability to enjoy life’s activities, relax, and concentrate (Boston Children’s Hospital, n.d.).

People with GAD may experience anxiety for months or years. It can also become chronic. Symptoms of GAD include (National Institute of Health, n.d.):

Becoming easily fatigued or feeling excessively tired.
Having feelings of restlessness or being “on edge.”
Having trouble focusing and concentrating.
Being irritable.
Having headaches, muscular pain, gastrointestinal disturbances, and unexplained feelings of pain.
Being unable to control feelings of worry and anxiety.
Having sleep disturbances such as trouble falling or staying asleep.

Violence Alert! Association between Domestic Violence and Eating Disorders

Research suggests that an estimated 30% of people with eating disorders have been sexually abused as children. The rates are higher for the development of bulimia nervosa and binge eating disorder compared to anorexia nervosa. Abuse is a nonspecific risk factor for eating disorders. It is important to remember that violence experienced as an adult can also increase the risk of eating disorders (Cowden, 2020).

Suicidal Ideation

Recent studies have explored the link between death by suicide and domestic violence. For example, Kafka and colleagues (2022) sought to address IPV as a precipitating factor for death by suicide. They focused on single suicides, defined as suicides unconnected to other violent deaths such as murder-suicides. Results of the study showed that IPV is a precipitating factor for 4.5% of single suicides. Most IPV-related single suicides were of those who committed nonfatal IPV, and people who died in IVP-related suicides frequently used a firearm and revealed their intent to die by suicide.

McManus and colleagues (2022) conducted a study to investigate the link between the experience of a lifetime and past-year IPV with suicidal thoughts, suicide attempts, and self-harm in the past year. The researchers analyzed the 2014 Adult Psychiatric Morbidity Survey, which is a cross-sectional study of 7,058 adults (16 years of age and older). Participants were “asked about experience of physical violence and sexual, economic, and emotional abuse from a current or former partner, and about suicidal thoughts, suicide attempts, and self-harm” (McManus et al., 2022).

Key findings include (McManus et al., 2022):

Sexual and emotional IPV seemed to be greater predictors of suicidal ideation and self-harm compared to those who experienced physical and economic IPV.
Participants who experienced multiple types of IPV violence tended to have greater chances of experiencing suicidal ideation, suicide attempts, and self-harm compared to those who only experienced one type of IPV.
Among participants who had attempted death by suicide in the past year, about 50% had at some time experienced IPV, and about 23% had experienced IPV in the past year.
One in three women who had attempted to die by suicide in the past year was a recent victim of IPV abuse, compared to one in 20 women in the rest of the population.
Findings related to ethnicity were unclear.

Violence Alert! Impact of Cyberstalking on Mental Health

Cyberstalking can have the same mental health impact as any other form of domestic violence. Cyberstalking can be just as distressing (and sometimes even more distressing) than other forms of stalking. The unpredictability of cyberstalking can be deeply disturbing as well as the fact that victims are typically unable to see or identify the stalker or know when they will stalk again. Research suggests that women are more likely than men to cyberstalk victims (Psychology Today, n.d.).

Impact of Domestic Violence on Physical Health

Physical violence can cause many types of injuries such as black eyes, broken bones, bruises, burns, and, in the aftermath of sexual violence, vaginal bleeding, unwanted pregnancy, sexually transmitted infections (STIs), and miscarriage (U. S. Department of Health & Human Services Office on Women’s Health, 2021).

A serious consequence of physical abuse is concussion and/or traumatic brain injury (TBI) that is the result of being struck on the head or falling and hitting the head. Symptoms of concussion and TBI include (U. S. Department of Health & Human Services Office on Women’s Health, 2021):

Headache.
Feelings of pressure in the head.
Confusion.
Dizziness.
Nausea and vomiting.
Slurred speech.
Memory loss.
Trouble concentrating.
Sleep disturbances.

TBI symptoms may not be immediately apparent and may not become evident for several days. Eventually, TBI may cause depression and anxiety and lead to problems making decisions and fulfilling obligations at work, school, and/or home. These kinds of symptoms may make it harder for someone to leave an abusive relationship. Survivors of physical violence should be encouraged to be evaluated for TBI (U. S. Department of Health & Human Services Office on Women’s Health, 2021).

Violence Alert! Behavior Issues due to Domestic Violence

To cope with the effects of domestic violence, survivors may misuse drugs and/or alcohol or engage in high-risk activities such as having unprotected sex or pursuing activities that involve danger (e.g., extreme sports) (U. S. Department of Health & Human Services Office on Women’s Health, 2021).

Domestic violence is also associated with a variety of long-term health disorders including (Arizona Coalition, n.d.; U. S. Department of Health & Human Services Office on Women’s Health, 2021):

Arthritis.
Asthma.
Cardiac disease.
Changes in eating and sleeping patterns.
Chronic fatigue.
Chronic pain.
Chronic stress.
Compromised immune system.
Gastrointestinal disorders.
Irritable bowel syndrome.
Involuntary tremors.
Migraines.
Muscle tension.
Nightmares.
Sexual dysfunction.
In women, problems with menstrual cycle or fertility.

Critical Thinking Scenario # 2

Maureen is a 27-year-old investment banker. She is good at her job and pleasant to her co-workers. However, she is very quiet and does not participate in any social activities organized by her workplace colleagues. Maureen has few friends and spends most of her leisure time alone in her apartment. Maureen has trouble sleeping and has nightmares about her parents when she is asleep. She also suffers from irritable bowel syndrome (IBS) and frequent migraines. Maureen has no contact with her parents and very limited contact with her older sister. Emotionally, Maureen is characterized as a “worrier.” She seems to worry all the time about everything, even issues that are inconsequential.

Sandy is one of her few friends. Maureen has known Sandy since they were children in the third grade. Sandy also is one of the few people who know that Maureen was severely emotionally abused by both of her parents. Maureen’s parents were community leaders and behaved charmingly to her in public. They were very popular and had many friends. In private, however, both parents constantly criticized and ridiculed Maureen but treated her older sister quite well. Maureen left home as soon as she turned 18 and put herself through college and graduate school.

Sandy encourages Maureen to be proud of her accomplishments and make new friends. Sandy offers to introduce Maureen to a few people at a small dinner party that she is planning. Maureen would like to have more friends and spend less time alone. But just the thought of meeting new people and attending social functions alarms her. She worries that her IBS will strike when she is meeting new people and she will have to leave the gathering. She “knows” that new people will soon find out how “inadequate” she is and ridicule her. It takes all her effort to perform well at work. Maureen says, “Work is the only thing I am even remotely good at. If I don’t focus on it, I’ll get fired and then what will I do?”

Maureen is dealing with the impact of severe emotional abuse. Are her physical and mental health issues associated with the impact of domestic violence?

Maureen suffered from years of abuse as a child and teenager. These factors may have influenced her ability to cope with the aftereffects of domestic violence. Abuse that continues for a long time at an impressionable age can compound its negative impact.

Maureen is displaying behaviors associated with the negative physical and emotional impact of domestic violence. Physically, Maureen suffers from IBS and migraine headaches. Both of these are treatable, but can be debilitating and occur without warning. If she has not done so, Maureen should talk to her primary healthcare provider about ways to manage both conditions and adhere closely to treatment recommendations. Physical discomfort affects her coping skills. Feeling well may very well enhance her ability to cope.

Domestic violence can lead to a multitude of mental health issues. Maureen is showing signs of GAD characterized by constant worry, even over issues that are inconsequential. She has a poor self-image and avoids interacting with others, characterizing herself as “inadequate.” It is appropriate for Maureen to be screened for other mental health disorders such as PTSD and depression, which may co-exist with GAD. The content of her nightmares should also be explored. If these nightmares involve “reliving” the abuse, PTSD may be an influencing factor on her mental and physical health. Feelings of inadequacy are often accompanied by ongoing sadness and hopelessness, which are characteristics of major depressive disorder. Treatment for survivors of domestic violence, including that of GAD and depression, is discussed later in this course).

Economic/Societal Impact of Domestic Violence

In addition to the devastating personal consequences of domestic violence, there is also a significant impact on the economy and society. Significant research has been done on the IPV type of domestic violence. According to the CDC (2022c), the lifetime economic cost associated with medical services for IPV-related injuries lost productivity from paid work, criminal justice, and other costs is estimated to be $3.6 trillion. Lifetime costs for women are $103,767 and $23,414 for men.

The Institute for Women’s Policy Research (2020) reported the following research findings on expenses and societal issues related to IPV, rape, and psychological abuse.

$41.5% of IPV assaults resulted in physical injury, 28.1% of which led to the need for medical treatment.
Healthcare costs for persons experiencing abuse were 42% higher than the costs for those who were not abused.
Experiencing abuse as an adolescent was associated with a decrease in the effort put into education and poorer academic performance.
Women who were victims of IPV during adolescence earned an average of 0.5 years of education compared to those who were not abused.
An estimated 60% of abuse victims reported having quit their jobs or being fired as a result of the abuse.
About 12.9% of participants acquired out-of-pocket expenses (e.g., attorney feeds, repairing property damage, child care costs) exceeded $1000.

Domestic violence has a negative impact on the ability of its victims to work. Fifty percent of women who were victims of sexual assault had to quit or were terminated in the first year following the assault. The total lifetime income loss for these women is almost $250,000 (U.S. Department of Health & Human Services Office on Women’s Health, 2021).

A 2018 survey provided a large amount of information about the costs related to domestic violence experienced by women. Eighty-three percent of participants reported that their abusive partners interfered with their ability to work. Of these women, 70% were unable to have a job, and 53% lost a job as a result of abuse. These issues interfere with victims’ career advancement and make them rely on their abusers financially, which makes it more difficult for victims to leave abusive relationships (Germano, 2019).

Reproductive coercion is also a consequence of domestic violence. Reproductive coercion is defined as “when an abuser tries to exert control over the reproductive health of a woman, which can mean sabotaging her birth control or forcing her to terminate a pregnancy’ (Germano, 2019).

Research findings suggest that 40% of the women who were victims of domestic violence reported that they had a partner who attempted to impregnant them against their will or prevented them from using birth control. Of these women, 84% became pregnant. Such unplanned pregnancies can interfere with career and educational aspirations. The costs related to pregnancy and raising a child may contribute to financial problems (Germano, 2019).

Healthcare professionals must consider how to incorporate these kinds of findings into efforts to prevent, as well as recognize, domestic violence. Research findings should be presented to all of them, such as during staff meetings, online, and in informal discussions.

Analysis of Barriers to Reporting Domestic Violence

Barriers to reporting domestic violence are varied. Some researchers suggest the following terminology changes to decrease the “blame the victim” attitude, which sometimes occurs to the dismay of people who have been abused. Instead of asking “Why do victims not leave?” ask “Why do people abuse?” Another important question to ask is, ‘why does societ continue to normalize and accept relationship violence?” (Gurm & Marchbank, 2020). These questions show that the focus of failure to report domestic abuse should shift from the victim to the abuser.

Normalization of violence is defined as “the acceptance that violence is an immutable part of life that depictions of violence do not have real-life consequences, and that it is the responsibility of the victim, not the perpetrator, to prevent violence” (WCASA, n.d.).

This normalization is seen in movies, television shows, video games, pornography, and commercial advertisements. These venues not only show violence as “normal” but often glamorizes or romanticizes it. The normalization of violence facilitates assault in the following ways (WCASA, n.d.).

Normalization of violence makes it acceptable and even expected as a normal part of society.
Societies that continually characterize men as inherently violent contribute to the sexualization of violence and romanticize abuse, particularly sexual abuse.
The media (e.g., television, movies, publications) sometimes support the ideas of violent masculinity and gender-based aggression.
Some institutions (e.g., military, fraternities, sports teams) depend on and encourage male aggression as a way of achieving success.

Threats of violence towards victims or their loved ones can stem from the normalization process. Abusers will go to extremes to keep their victims under control, including murder. The violence may be directed not only to the victims, but to their loved ones, pets, and property as well. Research findings indicate that leaving a perpetrator is the most dangerous time for victims. Another study consisted of interviewing men who killed their wives. Results showed that threats of separation or of leaving the abuser was the trigger that led to murder. Another study showed that 20% of homicide victims were not the actual victims of domestic violence, but family, friends, people who intervened, and law enforcement personnel (The National Coalition Against Domestic Violence (NCADC), n.d.).

Fear

Fear is a significant barrier to the reporting of domestic violence. Fear of bodily harm, fear that the abuser will harm the children or gain custody of them, and fear that the abuser will leave the victim financially destitute are all reasons victims have given for staying in the abusive relationship. Healthcare professionals must remember that victims are the people who best know their abusers, and they also know to what extremes these abusers may go to in order to maintain control over them (NCADV, n.d.).

For victims who are immigrants, there is the fear of being deported or losing their immigration status. If they are in the country illegally, they may fear being deported from their home and children (Gurm & Marchbank, 2020). Therefore, healthcare professionals should familiarize themselves with laws concerning immigration status.

The NCADV (n.d.) has identified the following fear factors that prevent a victim from leaving an abusive situation.

The abusers may become more violent, and even lethal if attempts are made to leave.
Victims worry that they have no safe place to go if they leave.
Abusers may gain custody of any children if victims leave the abusive situation.
Victims fear that they may become homeless if they leave the abusive situation.
Victims fear that family, friends, and/or law enforcement will not believe them.
Victims fear that if they tell someone, even law enforcement, about the abuse, they will not be believed or that the people they confide in will tell the abusers about their disclosures.

It is important to understand the extent of fear resulting from threats influences victims to remain in an abusive situation. Knowing the factors that increase the risk for homicide can help to identify victims most at risk. It can also help to decrease this type of barrier. The Los Angeles Police Foundation (n.d.) has identified factors that increase the likelihood of abusers’ likelihood to kill.

Homicidal or Suicidal Fantasies: Abusers who fantasize about killing their victims, children, others associated with the victims, and/or themselves are more likely to murder.
Threats: Abusers who threaten homicide or suicide are extremely dangerous.
Weapons: Abusers who have weapons or access to weapons are at higher risk of committing murder or death by suicide.
Obsessiveness: Abusers who obsess about their victims and/or believe that they cannot live without them are more likely to kill. Abusers may also believe that they are “entitled” to their victims, including the right to kill them if they try to leave the abusive situation.
Depression: If abusers are depressed and feel hopeless about feeling better, they may be more likely to commit murder or death by suicide.
Alcohol and Drug Consumption: Consuming drugs and/or alcohol when they are feeling hopeless or furious increases the risk of lethality.
Abuse of Pets: Abusers who batter and/or mutilate pets are more likely to kill family members.

Lack of Supportive Family or Friends

Victims may have no one to turn to for help when in abusive relationships. Family or friends may be unable or unwilling to help them. Victims may also find that family and friends do not believe that they are victims of domestic violence. This is especially true if the abuser has “hidden” the abuse and is perceived as charming and loving by others. Even if victims manage to leave abusive situations, they may find that they are financially destitute and/or that there are insufficient numbers of shelters for victims of domestic abuse. Even if there are options for seeking safety and shelter, victims may not know how to access them (Los Angeles Police Foundation, n.d.; NCADV, n.d.). Analysis of victims’ support systems must be a critical part of any patient assessment.

Emotional Factors

Victims’ emotions also play a significant role in reasons for staying in an abusive situation. Victims may profess love for their abusers or believe that the violence is somehow their fault. Some victims may believe that their abusers will change and their relationships will improve (Los Angeles Police Foundation, n.d.).

Victims may believe that their abusers are their only psychological and financial support system. This may be true, especially if the abusers have isolated their victims from family and friends. If abusers express remorse and promise to change, victims may believe that each abuse occurrence will be the last. Victims may even feel pity for their abusers, convincing themselves that only they can ‘save’ the abusers. They may feel guilt for not being able to help abusers stop the violence or shame because of their violent circumstances (Las Angeles Police Foundation, n.d.). Victims may also comment that they believe the abusers did not really mean to hurt them and did not want to deal with the challenges of going to court or publicly discussing the abuse (Gurm & Marchbank, 2020).

Researchers in the United Kingdom conducted interviews to explore victims’ perceptions and experiences of barriers and facilitators to reporting domestic violence. The researchers identified three themes for barriers to disclosure: emotional barriers, partner-related barriers, and organizational barriers. Emotional barriers were the most prevalent, with 69% of participants stating that one or more emotions prevented them from disclosing abuse to healthcare services. These emotions included embarrassment, shame, and fear (Heron et al., 2021).

Partner-related barriers included abusers’ controlling actions including accompanying them to healthcare appointments or other venues where they may disclose the violence. The abusers, in some cases, manipulated and charmed healthcare professionals, which reduced the chances of victims’ disclosing (Heron et al., 2021).

Organizational barriers included concerns about lacking adequate time to disclose the violence to healthcare professionals and reluctance to disclose abuse to their primary healthcare providers. They also commented that they believed that all women should be routinely screened for domestic violence. This finding highlights the importance of routine domestic violence screening by healthcare professionals (Heron et al. 2021).

Victims may have developed learned helplessness. They have been taught and believe that they are powerless and cannot survive without their abusers. Furthermore, they view their circumstances from the perspectives of the abusers and view the abuse from the abusers’ perspectives as well (Los Angeles Police Foundation, n.d.).

Some victims may experience what is referred to as the Stockholm or “hostage” syndrome. Victims who become part of this syndrome feel bound to remain in the abusive relationship and (Los Angeles Police Foundation, n.d.):

Believe that she and the abuser are bonded together.
Feel extremely grateful for any acts of kindness shown to them by the abusers.
Deny the violence or rationalize the violence.
Deny their own anger and fear.
Seek to keep the abusers happy and attend to their every need.

Concerns for the Children

Victims who have children often cite concerns directly relating to their offspring. They are frightened that their abusers will harm their children or gain sole custody of them. There is also the worry that abusers will simply “take” the children away and prevent them from seeing the victims again (Gurm & Marchbank, 2020).

Some victims believe that it is important to stay in the abusive situation for the “sake of the children.” Victims may think that their children need a father or mother (depending on the gender orientation of the abuser) and/or that keeping the family together is more important than escaping from the violence Compounding these issues is the concern and ambivalence over making significant life changes (Los Angeles Police Foundation, n.d.).

There also may be pressure from friends and family members not to break up their family. Feelings of guilt and shame over what victims may perceive as their “failure” to help the abuser as well as being “responsible” for breaking up the family (Gurm & Marchbank, 2020).

Financial Factors

Victims may be financially dependent on their abusers. They may not have access to cash, bank accounts, or other assets (e.g., the name is not on the deed to the home). If victims do have careers, their abusers may take control of any money paid to victims (NCADV, n.d.).

Some victims may have what appears to be a “good” life monetarily. Their abuser may earn a large income and the victims lead a comfortable life in terms of money. However, they may not have access to money and are dependent on the abusers to control the money to which victims have access. Additionally, the appearance of a good life provided for by money the abusers earn, may reinforce the illusion that victims have no reason to complain or charge someone with abuse. Financial pressure can be immense, and the thought of forfeiting such a lifestyle for themselves and their children is almost impossible (NCADV, n.d.; Scott, 2021)

Cultural/Societal/Religious Factors

Culture and religious perspectives influence how people dress, speak, eat, and view the concept of family and specific roles and responsibilities within families. It is critical that healthcare professionals comprehend the roles culture, religion, and society play in how domestic violence is regarded (Genesis, 2020).

Some cultures and/or societies teach women that their identities and “worth” are dependent on marrying, bearing children, and following the directions of the men in their families. Making domestic abuse public results in negative judgment and condemnation by members of the culture, leaving victims isolated and shamed. Members of the culture may view violence as normal and failure to make husbands “happy” is the fault of the victim. In other words, the abuse is their fault (NCADV, n.d.; Scott, 2021).

The components of some religions, as well as cultures, demand that marriage or relationships be maintained at all costs. Clergy and secular counselors may reinforce the belief that saving the marriage or relationship is the ultimate goal, rather than stopping the violence (NCADV, n.d.;(Scott, 2021). Religious, cultural, or societal beliefs and practices may view divorce and/or breaking up a family as wrong a source of shame and guilt, and even a reason to “punish” the victims (NCADV, n.d.).

Issues Concerning Male Victims of Domestic Violence

Domestic violence affects men as well as women. Most of the domestic violence research has been conducted on women. Traditionally, domestic violence initiatives focus on women as victims and men as perpetrators because women make up an estimated 85% of victims (Kippert, 2021).

Just as women struggle to report domestic violence and to be believed about its occurrence, men face similar struggles. Men have experienced domestic violence in the forms of being beaten, choked, burned, suffocated, and threatened with a weapon (Sheltering Wings, 2019).

An estimated one out of nine men has reported experiencing domestic violence. It is believed that this number is most likely an underestimate of the problem. Research suggests that it is the tendency of men to underreport experiencing domestic violence due to stereotyped gender roles and feelings of shame and embarrassment (Gills, 2021).

Female perpetrators often tend to rely on psychological abuse and manipulation, partly because they may not be able to overpower males. Examples of abusive psychological tactics include seeking revenge by spreading rumors, stalking, negative posts on social media, and forms of emotional abuse. These types of tactics may be more difficult to recognize and even more difficult to prove (Gills, 2021).

Being a male in cultures that socialize men to avoid discussing their feelings and concerns adds to the challenges of reporting. Many people, including healthcare professionals, believe that a man would be able to stop acts of domestic violence because they are physically “stronger” than women (Gills, 2021).

In addition to feelings of shame and embarrassment, men do not report abuse because of many of the same reasons women do not report. These include non-supportive family and friends, fear of not being believed, not wanting to break up a family, and concerns about the children (NCADV, n.d.).

Healthcare professionals must acknowledge that men are also victims of domestic violence and work to help them free themselves from violent situations.

Issues Concerning the LGBTQ Community

Domestic violence is at least as common in the LGBTQ community as in the non-LGBTQ community. Research suggests that bisexual and transgender people are at increased risk for IPV compared to the rest of the LGBTQ community (National LGBT Health Education Center, n.d.).

Members of the LGBTQ deal with the same types of barriers to reporting as any other domestic violence victim. However, shelter/housing issues add additional reporting barriers. For example (National LGBT Health Education Center, n.d.):

About half of LGBTQ survivors report being denied access to shelter, and nearly 33% of people who are turned away reported being turned away because of their gender identity.
LGBTQ survivors (especially those who identify as bisexual or transgender) may experience violence and discrimination in shelters.
Cisgender (people whose gender identify corresponds with the sex registered to them at birth) and transgender people may have problems finding shelters that accommodate their gender.
An abusive same-gender partner may try to gain access to the shelter where victims have taken refuge.

Implicit Bias as a Barrier to Reporting Domestic Violence

Analysis of barriers must include an evaluation of implicit bias. Implicit bias (also called unconsciousness) is a type of bias that occurs automatically and unintentionally. Although people are not aware of their implicit biases, their judgments, decisions, and behaviors are influenced by this type of bias. (National Institutes of Health, 2022).

Implicit biases held by healthcare professionals, law enforcement personnel, judges, and jury members can create significant barriers to the reporting of domestic violence. An example of such bias was presented in the publication U.S. Law Week (Zhan, 2020). A Black client suffered years of sexual and physical abuse committed by the father of her children. She eventually made the courageous decision to seek a protection order against her ex-partner. During the trial, the judge questioned her credibility because she did not report any of the prior episodes of violence and remained in an abusive relationship. The client explained that as a Black woman, she was distrustful of the police and afraid of what police might do to her former partner, who was also Black. She also pointed out that her home (with the former partner) was close to family who provided child care. The judge ignored the stressors that impacted her decisions and found her not to be credible. Furthermore, recent research findings suggest that some authority figures (e.g., judges and law enforcement) “view Black girls as less innocent…than their White peers” (Zhan, 2020). This suggests a “blame the victim” strategy.

In healthcare, implicit bias has been linked, to poor patient outcomes, inadequate treatment for chronic pain, and delays in diagnoses. It is imperative that healthcare professionals examine their own beliefs and behaviors to determine the existence of implicit bias. This is the first step in identifying and eliminating personal bias.

One strategy for self-analysis is the taking of the Implicit Association Test (IAT). This test measures attitudes and beliefs that individuals are unwilling or not able to report. The IAT is especially helpful in identifying implicit bias, thereby helping people learn about their unconscious biases (Health Care Access Now, n.d.).

Additional strategies for overcoming implicit bias include (Edgoose, et al., 2019):

Education: Education and training regarding self-introspection and implicit bias should be part of the continuing education activities of all healthcare organizations.
Mindfulness: Mindfulness is being in a state of awareness of the present moment and calmly acknowledging and accepting one’s feelings, and thoughts. Research findings indicate that increasing mindfulness via strategies such as meditation or yoga improves coping abilities and adjusts biological reactions that influence emotion and attention.
Perspective-Taking: This technique involves reaching beyond one’s comfort zone and perceive other persons of a stereotyped group from their perspectives.
Learn to Take the Time to Think: When interacting with someone in a stereotyped group, for example, one should analyze what personal responses are based on stereotypes and think about why such responses are occurring.

It is necessary to know that overcoming implicit bias is a lifelong process. There will always be new people and groups to encounter, some of which may trigger implicit bias. Healthcare professionals must incorporate strategies for overcoming and preventing implicit bias in their everyday lives.

Critical Thinking Scenario # 3

Jennifer is a trans woman who went public about a year ago. Her family has not been supportive and she has little contact with them. For the past six months, she has been living with Neil. At first, Jennifer was thrilled to have a loving partner who accepted her and supported her. However, as time went by, Neil’s behavior began to change. He began to criticize Jennifer’s appearance and demeanor, saying “You need to put more effort into your appearance. If I am going to introduce you to my work colleagues and family you need to look more attractive. I don’t want to be embarrassed. I am doing you a favor by living with you. I’m in charge here!”

Jennifer is devastated by these comments. It had taken a great deal of courage to go public as a trans woman, and she needs support, not criticism. The criticism continues, and Neil begins to make negative about Jennifer’s appearance and intelligence in front of their friends.

This emotional abuse escalates, and Jennifer starts to think about leaving Neil. When she tries to tell Neil what his comments are doing to her self-esteem and well-being, he becomes angry and threatens her with violence. He reminds Jennifer that she is dependent on him both financially and emotionally. She lost her job after identifying as a trans woman and relies on Neil’s monetary support. Jennifer has no support from her family, and her circle of friends is now comprised of Neil’s friends, who support him unconditionally. Feeling isolated and hopeless, Jennifer decides to ask her primary healthcare provider for information about shelter options for abused women. What challenges might Jennifer face as she attempts to leave this abusive situation?

Neil’s abusive behavior has shattered Jennifer’s self-esteem and confidence. Feelings of worthlessness typically hamper an abuse victim from planning escape. Such feelings contribute to the fear that is part of Jennifer’s circumstances. She relied on Neil for emotional support, which no longer exists. She relies on him for financial support. Additionally, Jennifer must face the prejudices inflicted upon trans people in society.

It is hoped that Jennifer’s healthcare providers are well-versed in the challenges trans people face. Finding a shelter can be problematic. Identifying as a woman, Jennifer may, or may not, be able to go to a shelter for women. Some shelters have begun to make accommodations for trans individuals, but there are not enough of these types of shelters to meet the needs of the LGBTQ community. They may be denied access to shelter based on their gender identity (e.g., a trans women may not be welcome at a shelter for women). LGBTQ victims, particularly trans and bisexual people, may become victims of violence committed by other residents in shelters.

Recognizing Victims of Domestic Violence

As healthcare professionals assess individuals for domestic violence, having knowledge of the Power and Control Wheel can help to identify the extent to which the abuse has escalated. Such identification will help to provide the most effective healthcare services.

Power and Control Wheel

Adapted from: Delaware.gov., n.d.; The Haven, n.d.

Coercion and Threats

The coercion and threats section of the Power and Control Wheel describes how the abusers may threaten to harm victims, the victims’ children, other loved ones, and/or pets. Abusers may also threaten to harm themselves. Threats of suicide by the abuser are quite common. Abusers may also force victims to commit crimes (Delaware.gov., n.d.; The Haven, n.d.).

Intimidation

Intimidation takes different forms. Abusers may use facial expressions (e.g., ominous looks, threatening language). Other intimidating tactics include destroying the victims’ property in front of them, displaying weapons, or harming or killing pets (Delaware.gov., n.d.; The Haven, n.d.).

Emotional Abuse

Abusers may belittle and/or embarrass victims in private and in front of others. Victims are subjected to constant criticism and insults, which destroy their self-esteem. Abusers blame the victims for the abuse, causing them to doubt their own beliefs and feelings and even to question their own sanity. One of the primary characteristics of emotional abuse is the constancy of the abuse (Delaware.gov., n.d.; The Haven, n.d.).

Isolation

The ultimate goal of isolation is to completely cut the victims off from anyone who might be able to help them leave the abusive relationship. Victims may not be allowed to leave their homes and may also be forbidden from making and receiving telephone calls. Contact with family and friends is gradually limited until there is no contact whatsoever (Delaware.gov., n.d.; The Haven, n.d.).

Minimizing, Denying, and Blaming

Abusers often minimize or deny that their actions are harmful, even if injuries occur. Abusers may even deny that the abuse ever took place. Blaming victims for the abuse is part of the blaming process. Telling victims that the abuse is their fault may make victims accept some or even all of the responsibility for it (Delaware.gov., n.d.; The Haven, n.d.).

Using Children

Children are often used to gain or maintain control over the victims of abuse. Abusers may threaten to harm or kidnap the children, telling victims that they will never see their children again. Another tactic is to heap guilt on victims for breaking up the family if they leave (Delaware.gov., n.d.; The Haven, n.d.).

Male Privilege

The North Dakota State University (n.d.) defines male privilege as “the undue advantage that benefits men in male-dominated organizations and societies.” Privileged males may treat victims like servants, expecting them to cater to their every whim. These types of males expect to make all decisions and define women’s roles as subservient to men (Delaware.gov., n.d.; The Haven, n.d.).

Use of the Power and Control Wheel has evolved to include both women and men as using the power of privilege. Abusers can be people of any gender or sexuality. The Wheel can be used to study the tactics abusive partners us to keep their victims in an abusive relationship (Delaware.gov., n.d.; The Haven, n.d.).

Signs and Symptoms of Physical Abuse

Injuries due to physical abuse may or may not be apparent. Some abusers make sure to injure their victims in areas that are usually covered by clothing. However, there are some characteristics of physical abuse that can help healthcare professionals to recognize and intervene in cases of suspected abuse.

Signs and symptoms of physical abuse are plentiful. These include black eyes, welts, lacerations, rope marks, burns, broken bones, bruises, open wounds, and multiple injuries in various stages of healing. While injuries can be due to accidents, evidence of physical injuries in locations such as over the breasts or buttocks, bilateral injuries, or burn marks or bruises that resemble specific objects used to inflict injuries (e.g., a belt buckle) are highly suspicious of being the result of abuse (Washington State Department of Social and Health Services, n.d.).

Signs in Children

In order to differentiate an accidental from a deliberate injury, healthcare professionals must assess the full extent of the injury and understand the abilities associated with the child’s development level (Giardino, 2022).

In addition to the signs and symptoms found in adults, indicators that should trigger suspicion of child abuse include signs such as poor hygiene, bruising in non-ambulatory children, and injury patterns that are inconsistent with the history of the injury provided. Bruising of ears, facial cheeks, buttocks, palms, soles, neck, and genitals are also suspicious (Giardino, 2022).

Bone injuries/fractures in children less than two years of age may not be obvious, so experts recommend a skeletal survey to identify fractures. Healthcare professionals must evaluate the presenting signs and symptoms and conduct screening as appropriate. Suspicious of child abuse should never be ignored. Although fractures may be accidental, the following types of fractures that are highly suspicious of abuse include (Giardino, 2022):

Any fracture in a non-ambulatory infant without a clear, plausible, description of the accident that caused the injury.
Metaphyseal fractures (injury to the metaphysis, which is the growing plate at each end of a long bone such as the tibia or femur).
Multiple, complex skull fractures.
Multiple, bilateral, differently aged posterior rib fractures.
Fractures of the scapular.
Fractures of the spinous process.

Signs and Symptoms of Emotional Abuse

Emotional abuse is the purposeful causing of emotional pain and damaging victims’ self-esteem. Because emotional abuse itself does not cause overt injuries it may be difficult to recognize. Signs that someone may be experiencing emotional abuse include (Gillette, 2022; Washington State Department of Social and Health Services, n.d.):

Social withdrawal, non-responsive.
Fear and nervousness around other people, especially the abuser.
Low self-esteem.
Does not participate in discussions or making decisions.
Feelings of anxiety and no sense of self-worth.
Nervousness around other people.
Agitation.

Emotional abuse is sometimes overlooked because there may be no physical evidence. It is imperative to include assessment of the possible victim’s emotional status.

Signs of Sexual Abuse

Sexual abuse, the committing of non-consensual sexual activity, can cause a variety of signs including (Tameside Metropolitan Borough, n.d.; Washington State Department of Social and Health Services, n.d.):

Soreness and/or bruising around the genitalia.
Unexplained sexually transmitted infections (STIs) or genital infections.
Unexplained vaginal or anal bleeding.
Torn, stained, or bloody underwear.
Preoccupation with anything sexual.
Pregnancy.
Unexplained behavior changes.

Violence Alert! Victims of Sexual Abuse

Sexual abuse can affect persons of any age or gender. It can also occur in any location such as long-term care facilities, hospitals, homes, or cars.

Signs of Neglect and Abandonment

Neglect is when someone deprives someone of the necessities to maintain health and well-being. Additionally, self-neglect (failure to provide adequately for oneself jeopardizing health and well-being), can also be a form of abuse (Washington State Department of Social and Health Services, n.d.).

Signs of neglect are typically observable. Persons suffering from neglect may experience dehydration, malnutrition, untreated bed sores, and have poor personal hygiene. Victims of neglect may live in hazardous or safe conditions such as having no running water or heat. Victims may also live in unsanitary and unclean conditions. For example, there may be dirt, flees, or lice on victims, bedding or other areas of the home may be soiled with urine and/or feces (Washington State Department of Social and Health Services, n.d.).

Self-neglect includes a variety of behaviors. People may fail to take care of their personal hygiene, refuse to take their medications, fail to eat properly, or stay adequately hydrated. They may neglect their surroundings, allowing their homes to become dirty, or fail to pay bills, which may lead to loss of electricity, running water, etc. (Tameside Metropolitan Borough, n.d.).

Abandonment occurs when a vulnerable adult or child is deserted in a public space such as a grocery store. Victims may also be abandoned in their homes or living spaces (Washington State Department of Social and Health Services, n.d.).

Reporting Domestic Violence

Mandatory reporting is defined as “a legal procedure that involves reporting confirmed or suspected cases of abuse and neglect” (Scrubs & Beyond, 2022). The definition of mandatory reporters varies from state to state. Mandatory reporters are typically people who work with or provide care to vulnerable populations. In most states, mandatory reporters include healthcare professionals, social workers, teachers, law enforcement, and clergy (Scrubs & Beyond, 2022).

In 1994, Congress passed the Violence Against Women Act (VAWA). This act, including additions made in 1996, 2000, and 2005, recognizes domestic violence as a national crime. The following are identified as federal crimes under the VAWA “if they are committed within the maritime or territorial lands of the U.S., or if the offender crosses state lines, foreign lines, or enters or leaves Indian country to” (U. S. Attorney’s Office, 2021):

Commit or attempt to commit a crime of violence against an “intimate partner” 18 U.S. C. Section 2261.
Stalk or harass or to stalk or harass by mail or computer 18. U.S.C. Section 2261.
Violate a qualifying Protection Order 18 U.S.C. Section 2262.

However, there is a significant amount of variation among state domestic violence laws. More than half of the States place domestic violence definitions and penalties within the criminal code and almost every state provides definitions within domestic relations or social services codes. Definitions of the different types of domestic violence, penalties for domestic violence, and who are identified as mandatory reporters also vary among states (National Conference of State Legislatures (NCSL), 2019. Therefore, it is imperative that all healthcare professionals know their respective states’ laws and mandates regarding domestic violence.

Most states’ reporting laws are part of one of the following four categories (Mandated Reporter Training, 2023).

States that require reporting of injuries caused by weapons.
States that mandate reporting of injuries caused in violation of criminal laws.
States that specifically mandate domestic violence reporting.
States that have no mandated reporting laws.

Violence Alert! Protection for Mandated Reporters

Depending on state law, healthcare professionals and other mandated reporters are protected from civil and criminal liability if acting in good faith when reporting abuse. Healthcare professionals MUST know not only their state mandates but also the policies and procedures that govern reporting in their respective healthcare organizations.

Typically, healthcare organizations have policies and procedures that cover the reporting of domestic violence. How to report violence should be part of the orientation of all new employees and periodically reviewed.

Failure to Report

Penalties for failure to report depends on the type of abuse and the state in which the abuse takes place. Upon conviction, a mandated reporter who fails to report abuse can face jail terms ranging from 30 days to five years, fines that range from $300 to $10,000, or both jail terms and fines. Under certain conditions, in some states, even harsher penalties may be imposed (Child Welfare Information Gateway, 2019).

Penalties for False Reporting

There are also penalties for false reporting. In some states, someone who deliberately makes a false report of abuse can face severe penalties. False reporting is classified as a misdemeanor or a felony depending on state laws. The false reporter may also be held civilly liable for any damages caused by the false report (Child Welfare Information Gateway, 2019).

Critical Thinking Scenario # 4

Marcie and David are the parents of 15-month-old Michael. The family is experiencing some tough financial circumstances because David has recently lost his job, and Marcie works part-time as a teacher’s aide. They have been stressed and worried about possibly being unable to pay their mortgage. They bring the baby to the community medical center emergency department (ED) at around 6 pm. Michael is crying and his right arm is swollen from the wrist to the elbow. His parents are very upset and tell the triage nurse that Michael was playing with his father in their backyard. The baby is starting to walk, and his father is encouraging him to continue walking to him. Michael loses his balance and falls, striking his arm on a wheelbarrow that David forgot to put back in the garage. Michael is crying loudly, the arm continues to swell and seems to be positioned at an odd angle.

Both parents are tearful. David tells Stacy, the triage nurse, “This is all my fault. I should have been closer to him but he was so happy and walking so well. Now he’s hurt and it’s my fault! Things have been so hard lately but he is the only thing that can make us smile! What are you going to do? He needs x-rays and tests to see if his little arm is broken.” Another nurse asks David to step out of the room briefly to sign some treatment papers, giving Stacy a chance to talk to Marcie alone. David leaves the room readily, telling little Michael that “Daddy will be right back” Marcie explains that she had been inside the house and did not see the actual fall but rushed outside when she heard Michael crying. At that point, Marcia saw Michael lying near the overturned wheelbarrow. Marcia tells Stacey that, “Our little boy is the only bright spot in our lives right now. Unless David finds a job soon, we may lose the house. He adores Michael and is heartbroken about this accident.” When David re-enters the room, little Michael immediately holds out his arms to him to be held.

Another couple soon comes to the ED with their three-year-old daughter, Allison. Mason, the triage nurse, recognizes the couple as prominent attorneys in the community. They are generous donors to the medical center and have the reputation as being equally generous to other community charitable causes. Their daughter seems frightened and is silent, refusing to tell the nurse her name. She also avoids looking at her parents. The parents, Elizabeth and Edward, explain that their daughter is “clumsy” and falls frequently. They brought her to the ED because Allison kept complaining that “my arms hurt.” Elizabeth explains “we are going out of town on vacation tomorrow, and Allison will be staying with her nanny. She’s crying so much we thought she should be checked before going away and leaving the nanny responsible for something we should have taken care of.” Assessment findings show severe bilateral bruising on the child’s upper arms. Mason notes other bruises over Allison’s chest and buttocks. These bruises are in various stages of healing. Mason suspects abuse. He is concerned, not only for Allison but for himself. The parents are powerful people who have friends in leadership positions throughout the community, including the medical center. He knows he must report his suspicions, but dreads dealing with the possible consequences of reporting people who are well-known and influential in the community.

Both of these scenarios involve children who may, or may not, be victims of abuse. In the first scenario, the family is dealing with financial instability due to job loss. This is causing a great deal of stress, and stress can increase the possibility of abuse. However, both parents express the love of their child as a priority in their lives and a source of joy. David and Marcie both seem to be genuinely distraught. Little Michael, upon his father’s return to the treatment room, held out his arms to him for comfort.

The injury and its circumstances, as described, seem to be factual. David appears to be devasted and asks the nurse about treatment, including x-rays. The injury affects only one limb, and there is no evidence of other injuries. There is no evidence to indicate that Michael is the victim of abuse.

The circumstances of the second injury are more problematic. During the assessment, Mason finds that Allison is unusually withdrawn and seems to be avoiding contact with her parents. He also notes that severe bruises are evident on both of the child’s upper arms. There are also bruises in various stages of healing over Allison’s chest and buttocks. There are several alarming findings that strongly suggest abuse. Rather than seeking comfort from her parents in this frightening situation, the child avoids them. Her injuries are also indicative of abuse. Bruising over the chest and buttocks are not part of the “normal” bruising from accidents. Bilateral bruising over both upper arms could suggest that Allison has been grabbed hard enough to cause injury.

Adding to the complexity of the situation is the fact that Allison’s wealthy parents are prominent in the community and frequent financial donors to the community, including the medical center where Mason works. Legally and ethically, Mason must report his suspicions. However, it is also true that reporting such persons may have ramifications. Although the state in which Mason practices offers immunity from prosecution and the reporter’s name is not disclosed to the suspected abusers, Mason worries that Allison’s parents will assume he is the reporter. Sadly, this is a possibility. The law protects Mason and policy should mandate that there is no punishment or recrimination for reporting.

Reporting is never an easy process, no matter the circumstances. Mandated reporters must adhere to the legal and ethical standards that govern their professional practice.

Intervening when Domestic Violence is Suspected

The first step in domestic violence intervention for healthcare professionals involves advance preparation. Before facing a situation involving possible domestic violence healthcare professionals must know:

State laws that govern domestic violence and reporting mandates.
Organizational policies and procedures that direct healthcare professionals’ response to suspected domestic violence.
How to identify signs and symptoms of each type of abuse.
How to interact with possible victims of abuse.

It is not necessary for healthcare professionals to solve or have a solution for survivors of domestic violence. Options, such as giving victims the number of the domestic violence hotline and/or the opportunity in a private setting to make a call are appropriate, but healthcare professionals cannot “make” someone take steps to escape an abusive situation (Futures without Violence, n.d.). This can be difficult for healthcare professionals to accept. Their instinct may be to “do what is best for the patient, no matter what.” However, forcing someone to file domestic violence reports is generally not in the best interest of the patients, who know their situations and the consequences of reporting better than anyone. For example, offering ways to contact healthcare providers or domestic hotlines is the best strategy.

The goal is to be present and unconditionally supportive of these victims. Part of being present includes directly asking the victims if they are experiencing abuse. Research findings from surveys of women who experienced IPV indicate that a direct inquiry from a supportive healthcare professional helped them to disclose their abuse and find appropriate services to help them. Research shows that simply asking about abuse is an important intervention when working with victims of domestic violence. This intervention can help with early identification and intervention, which is linked to the prevention of serious disability and death (Futures without Violence, n.d.).

Screening

Before proceeding with screening, healthcare professionals must establish trust with victims. Choosing screening tools that help healthcare professionals demonstrate empathy and knowledge are imperative. When asking screening tool questions, it is important to (Morris, 2022):

Avoid talking down to victims.
Remain objective; do not judge.
Be patient.
Be reliable.
Ask permission before touching victims.
Remember that victims can be of any gender or sexual orientation.

Screening Tools

Experts recommend that domestic violence screening questions be part of all routine medical histories and assessments. By doing this, screening becomes more conversational and facilitates the consistent screening of all patients regardless of whether or not abuse is suspected (Morris, 2022).

Jamie Ferrell, the director of forensic nursing services at Memorial Hermann Health System in Houston states that “An effective screening is done by creating a safe space with privacy, seeking to understand, not judge, being intentional with communication, and slowing down to hear.” Organizations should adopt screening tools appropriate to patient settings so that there is consistency in screening and documentation.

Violence Alert! Establishing Trust

As part of a trusting environment healthcare professionals must not question victims as though they were being interrogated. Interrogation can retraumatize victims during questioning. Additionally, some experts recommend that healthcare professionals inform victims that they are mandated reporters before initiating discourse. This allows victims to choose whether or not to disclose domestic violence with the understanding that the mandated reporter will be informing others (e.g., law enforcement, and social service agencies) about the possibility of abuse (Morris, 2022).

Hurt, Insult, Threaten, Scream (HITS)

The Hurt, Insult, Threaten, Scream (HITS) is a four-question tool that can be self-reported or administered by healthcare professionals. Scoring is accomplished using a five-point scale from 1=Never to 5=Frequently. Questions focus on assessing the frequency of certain components of IPV. Total scores can range from four to 20. A score of 10 or higher is an indicator that the person is at risk for IPV (Morris, 2022).

Humiliation, Afraid, Rape, Kick (HARK)

The Humiliation, Afraid, Rape, Kick (HARK) is a four-question screening tool that is self-reported. Questions focus on different components of abuse including emotional, sexual, and physical abuse. Another version of HARK (HARK-C) asks one additional question about whether or not children have been exposed to violence. Questions are answered with a yes or no. One point is given for every “yes” answer. A score of one or more implies that IPV has been experienced in the past year (Morris, 2022).

Relationship Assessment Tool (RAT)

The Relationship Assessment Tool (RAT) consists of 10 questions about various aspects of behaviors of partners’ and victims’ feelings. Training information is available from Futures without Violence (https://www.futureswithoutviolence.org). Responses are measured on a six-point Likert scale with 1=Disagree Strongly to 6=Agree Strongly. A score of 20 or higher is indicative of IPV (Morris, 2022).

Ongoing Violence Assessment Tool (OVAT)

The Ongoing Violence Assessment Tool consists of three yes/no questions that ask about violence experienced within the past month. For example, one question asks if a partner has threatened the victim with a weapon. A fourth question asks victims to rate their partner’s respect for the feelings of the victim. Answers range from Never to Very Frequently (Weiss, n.d.).

Violence Alert! Screening Tools

The preceding examples of domestic violence screening tools are only a sampling of the many tools available for use. Healthcare organizations should identify what tool (or tools) are most appropriate for their respective facilities. Staff members should be taught how to implement selected screening tool(s) so that there is consistency in administration and scoring of answers.

Danger Assessment Tool

The Danger Assessment Tool is used to assess the risk of severe violence and is an interactive decision aid to facilitate the victims’ abilities to plan for their safety and implementation of actions to leave an abusive situation (Ramaswamy et al., 2019).

Jacquelyn Campbell, PhD, RN, FAAN, created the Danger Assessment Tool in 1985 Campbell, 2019). The goal of the Danger Assessment Tool is to help identify the level of danger a domestic violence victim has of being killed or nearly killed by their intimate partner or ex-partner. This 20-item tool is intended to be used with survivors to educate them about their risk of dying, or nearly dying, and to facilitate their decision-making. Note that the Danger Assessment tool is not to be used as a screening tool for the presence of domestic violence, nor should it be used as a stand-alone housing assessment tool (National Network to End Domestic Violence, n.d.).

The Danger Assessment Tool uses a weighted scoring system to count yes/no responses of risk factors linked to intimate partner homicide. For example, respondents are asked if their partners owned firearms, if their partners had ever threatened to kill them, etc. The tool is available in English, French Canadian, Portuguese, and Spanish (Family Justice Center Alliance, 2019).

Assessment

Physical assessment findings and their documentation are critical. Suspicions of abuse should not be mentioned in the medical record. Instead, objectively document what is seen, smelled, etc. without charting assumptions, suspicions, or guesses. Emotional assessment findings must also be objectively documented e.g., what possible victims say, what people who accompany the possible victim say, behaviors, etc. (Ramaswamy et al., 2019).

Violence Alert! Immediate Life-Threatening Circumstances

If the victim’s life or the lives of staff members are in immediate danger because of the perpetrator’s actions, security, and law enforcement should be called immediately!

Asking Questions

When screening for domestic violence it is imperative that the interview be conducted in a way that establishes trust and objectivity. Appropriate, qualified interpreters may be needed. These interpreters are governed by the same confidentiality mandates as healthcare professionals. Professional language interpreters (not someone who is associated with the patient) should be used (ACOG, 2022).

Screening interviews must be conducted in a private, safe environment with the victim alone. The interview should not be conducted in the presence of partners, other family members, friends, or caregivers since it is not known who may be participating in or ignoring/denying the abuse (ACOG, 2022).

Violence Alert! Universal Screening

Screening for domestic violence should be part of the routine medical history, assessments, and routine visits. Standardized assessment forms should include questions to screen for domestic violence. This ensures that all patients are screened whether or not abuse is suspected (ACOG, 2022).

ACOG provides samples of questions used to screen for domestic violence (ACOG, 2022).

Framing statements can help to set the tone. For example, healthcare professionals might say, “We have started to talk to all patients about safe and healthy relationships and homes because these can have a big impact on your health.”
Confidentiality must be ensured. Healthcare professionals might say something like, “I want you to know that everything you tell me is confidential. I won’t talk to anyone else about what you say unless you tell me that (ACOG recommends that telling the victim what they are obligated to disclose according to state law).
Questions about injuries must be framed in language that is understandable to both healthcare professional and victim. For example, “Has your partner ever hit, slapped, kicked, choked or physically hurt you in any way?”
Females of reproductive age might be asked, “Does your partner support your decision about when or if you want to become pregnant?”

When asking screening questions, it is important to remember that not all victims respond the same way to a particular screening approach. Screening for domestic violence can be done in writing with oral follow-up or orally.

Stanford School of Medicine at Stanford University has published a variety of sample questions that can be used in the screening process as well as suggestions for implementation. Samples have been group into categories of written questions, oral questions, asking indirectly, and asking directly (Stanford School of Medicine, n.d.b.).

Written Questions. Written questions are time-efficient, but some victims may respond to yes/no questions by checking “no” even if they are in an abusive environment. Written questions should always be followed up with clarification such as, “I see that you have checked “no” for this/these questions. If you have any questions about this issue or if anything like this problem ever occurs, this is a safe place for you to come and talk about it.” This way, the healthcare professionals are not “challenging” the victim but are offering an option to think about and, perhaps, share information (Stanford School of Medicine, n.d.b.).

Violence Alert! Documentation

If using a written screening tool, it is important for healthcare professionals to sign off on the form and/or document in records the results of the screening tool. This is not a supposition, results can be documented as an objective finding (Stanford School of Medicine, n.d.n.d.b.).

Oral Questions. Oral questions should be incorporated at routine and new healthcare appointments. The importance of routine screenings cannot be over-emphasized.

Indirect Questions. Indirect questions are general in nature and facilitate sharing of information. Samples of indirect questions include (Stanford School of Medicine, n.d.):

How are things going at home?
How would you describe the important relationships in your life?
How does you partner treat you?

Direct Questions. These types of questions directly, specifically, address the issue of domestic violence. Examples include (Stanford School of Medicine, n.d.b.):

Are you afraid of your partner? Are you afraid of anyone who is part of your intimate relationships? (e.g., parent, caregiver, etc.).
Do you feel you are in danger from your partner, adult child, caregiver, etc.
Has anyone close to you ever threatened to hurt you? What did they say or do?
Have you ever been touched in ways that made you uncomfortable? If so, what were the circumstances?
Have you ever been forced to do something sexual when you did not want to?
What kinds of violence have you experienced in your life? (physical and/or emotional).
In an emergency, do you have somewhere safe to go?

Education and Training

Education and training are essential to victim survival. It is also essential that healthcare professionals are adequately trained and educated in the recognition, intervention, and prevention of domestic violence. Adequately educated and trained healthcare professionals have the skills, knowledge, and confidence to work with victims and colleagues to achieve the best possible outcomes (ACOG, 2022).

Educating Victims/Survivors

Even if victims deny abuse or decide not to press charges, healthcare professionals must provide them with access to available resources in the community. Resources might include information about shelters, domestic violence hotlines, and how to develop an emergency safety plan if leaving the abusive environment becomes an urgent priority. However, information about such resources must be provided as discreetly as possible. If the abuser finds out that resources and/or education have been provided, abuse may accelerate (Maynard, 2023).

Violence Alert! Knowing about Resources

In order to provide victims with information about domestic violence community resources, healthcare professionals must know what they are. It is the responsibility of healthcare professionals to educate themselves about resources for victims of domestic violence. It is also their responsibility to evaluate if the education has been effective. Questions such as “Do you know how to use the Domestic Violence hotline?” are not appropriate. The victim may simply reply “yes” to end the interview. Avoid questions that can be answered with a “yes” or a “no.” Instead, ask victims to tell the healthcare professionals what they would do to access the Domestic Violence Hotline. This allows the healthcare professional to accurately access the victim’s knowledge.

Educating Healthcare Professionals

Adequately trained and educated healthcare professionals must be motivated to “make a difference” in the recognition and prevention of domestic violence. Training programs must include topics such as (Hegarty et al., 2020; University of California, 2022):

Descriptions of the various types of domestic violence.
Recognition of the sign and symptoms of domestic violence.
Explanation of the impact of domestic violence.
Explanation of risk factors for domestic violence.
Compliance with mandatory reporting laws and organizational mandates.
Discussion of the limits of confidentiality.
Description of appropriate communication methods.
Description of various screening tools for domestic violence.
Explanations of the screening, counseling, and intervention processes.
Documentation of assessment findings.

Documentation

Medical records are frequently used as evidence in domestic violence cases. It is imperative that documentation be factual, clear, and concise. Proper documentation can assist the victim’s attorney to obtain a restraining order, qualify for exemptions in public housing, welfare, and health and life insurance, compensation for victims, and resolution of landlord disputes (A Train Education, 2023).

Any injuries must be documented objectively. Healthcare professionals should document the following items (A Train Education, 2023; Stanford School of Medicine, n.d.a.).

Photograph injuries, if possible, while adhering to legal and organizational standards.
Describe injuries factually. Include the exact location of injuries, size, and appearance. Use a body map or location map to identify the location of injuries.
Use quotation marks to document victims’ own words, indicating the exact repetition of what was said. Do not paraphrase. Identify who said the comments within the quotation marks. For example, “my wife hit me with a shovel,” or “partner states, “my child is clumsy. That’s why he has all those bruises.”
Avoid documenting assumptions or personal conclusions such as, “It looks as though the patient is a victim of abuse.” Stay objective and factual.
Document any referrals made and any information/education given to victims.

Developing a Safety Plan

Victims of domestic abuse should be helped to develop a safety plan. A safety plan is designed as “a plan that you create before you actually need to use it (Texas Rio Grande Legal Aid, 2022).

Even if victims are not ready to leave abusive situations, they should be encouraged to develop a plan in case of emergencies. Experts recommend that a personal safety plan be developed in stages (Texas Rio Grande Legal Aid, 2022).

Emergency Plan

If the abuse and/or threats are verbal it is best to leave before the situation accelerates. Victims should stay away from rooms with just one entrance, where weapons are stored, or near objects that could be used as weapons. Exits that can be used quickly should be identified. If abusers are threatening or assaulting victims, 911 should be called as soon as possible. Medical attention should be obtained and injuries should be photographed over a period of several days, since bruising can develop over a period of time. For victims who do not have health insurance, funding may be available if charges are pressed (Texas Rio Grande Legal Aid, 2022).

Violence Alert! Finding a Safe Place to Go

Victims should know the location of their nearest emergency shelter. The 24-hour domestic violence hotline workers can tell victims the location of the nearest shelters. The number is 1-800-799-7233. It is also recommended that victims ask neighbors to call 911 if violence is suspected. A pre-arranged code word for help should be identified. Code words should be set up with family and friends as well (Texas Rio Grande Legal Aid, 2022).

Emergency Go Bags

An emergency bag should be packed and stored in a place that the abuser cannot find. If necessary, the bag could be kept at the home of a trusted relative or friend. Important telephone numbers can be part of the emergency go bag, but it is recommended that these numbers (e.g., local law enforcement, trusted friends and relatives, domestic violence hotline number, numbers of local shelter(s) if known. The go bag must contain necessary medications, some cash, a spare car key, cellphone charger, burner iPhone, and clothing (Women in Safe Homes, n.d.).

Copies of important documents should be placed in the go bag. These documents include (Texas Rio Grande Legal Aid, 2022; Women in Safe Homes, n.d.).

Driver’s license or other identification.
Passports.
Birth Certificates or adoption papers.
Social Security cards.
Green cards or naturalization papers.
Medical insurance cards.
Checkbooks.
Financial records (e.g., bank statements, tax returns and W-2s).
School records.
Marriage license or divorce papers.
Child support orders.
Copies of restraining orders.
Lease or mortgage information.
Wills.
Vehicle titles.
Proof of benefits or disability documentation.
Important addresses and telephone numbers.
Immunization records.

Violence Alert! Safety Planning with Children

Children should be taught that their primary concern is to stay safe, not to protect adult victims. Have a code word or phrase that children can easily remember. These code words can be used as a signal to leave, hide, or get help. Children should be taught how to dial 911 and to memorize their addresses and telephone numbers. They should also be taught what safe places are in the home (e.g., locked room, under beds) and where to go outside the home (e.g., friends, relatives, neighbors) (Texas Rio Grande Legal Aid, 2022).

General Recommendations

Escape plans should be practiced and children should be included in the practice sessions. Victims should keep their cellphones fully charged and with them at all times. A location of where to meet with children or other family members if victims leave the abusive situation. When driving, the car doors should be kept locked and gas tanks full or electric cars fully charged (Women in Safe Homes, n.d.).

Victims are encouraged to keep a journal of abusive incidents including dates, times, a description of the events, pictures of any injuries, and any threats that were made. The journals are to be kept in a safe place, which cannot be accessed by the abuser. Abusive communications should be saved. Threating text messages, social media posts, emails, or voicemails should be preserved. Social media accounts should be kept private (Women in Safe Homes, n.d.).

After leaving an abusive situation there are a number of actions that survivors should take to facilitate safety. If legal charges have been filed, they should keep track of the legal process. If there are financial issues interfering with the pursuit of legal help, legal aid agencies may be able to help (Texas Rio Grande Legal Aid, 2022).

The locks of the victim’s residence should be changed, and window latches should be tested to see if they are secure. Locks on garage doors and other entries should be changed. Doors should be kept locked at all times. If feasible, a security system should be installed, motion detectors put in place, and outside lighting installed. Neighbors should be informed that the abuser is not welcome on the survivor’s property and asked to call law enforcement if the abuser is seen on the property (Texas Rio Grande Legal Aid, 2022).

Travel routes and travel routines (route to work, taking children, etc.) should vary as much as possible. Cell providers and cell phone numbers should be changed. If there are landlines in the home those numbers should be changed as well. Papers/documents should be shredded before putting them in the trash. If abusers must be met in person (e.g., to exchange children for visitation) the meeting should take place in a neutral and public location. Meetings should not take place in either residence. It is best if the survivors bring a friend or family member with them to the meeting (Texas Rio Grande Legal Aid, 2022).

Violence Alert! Precautions for Children

Children’s schools and day cares should be informed about who is allowed to pick up the children (Women in Safe Homes, n.d.).

Counseling and Psychotherapy

All survivors (and those who are still in abusive environments) should consider participating in professional therapeutic counseling whenever possible. Abuse can have severe physical and emotional consequences. It is important that those who have experienced domestic violence have a safe place where they can talk and not be judged. Counseling can help people to explore healthier life choices and stop abusive circumstances. Domestic violence counseling may be helpful for people who are currently dealing with domestic violence as well as those who have been abused in the past (Clewley, n.d.).

Counseling should be provided by professionals or agencies with expertise in domestic violence counseling. Types of domestic violence counseling include (Gupta, 2022):

Individual counseling: Persons affected by domestic violence can speak to counselors one-on-one about their feelings, experiences, and the impact the violence has had on them. This type of counseling acknowledges that people experience and react to domestic violence in different ways. Individual goals are established to help develop healthier ways of living.
Integrative therapies: These are initiatives such as yoga, meditation, and mindfulness. Mindfulness involves becoming more fully aware of the present moment in an objective and non-judgmental way and not dwelling on the past or projecting into the future (Scott, 2022).
Support groups: Support groups concentrate on the shared experiences of members and help them to know that they are not alone. Shared understanding can help to promote well-being.
Creative arts therapies: These therapies are characterized by different artistic modalities such as music, dance, and writing.
Couples therapy: Couples therapy can be controversial because there may be a safety risk to the survivor. Couples should be carefully evaluated and a safety assessment conducted before starting therapy. Safety measures (e.g., security presence nearby; not allowing abusers to sit between the victim and/or counselor and the exit) must be implemented during all therapy sessions.

Research findings indicate that psychotherapy can be of benefit to people who experience domestic violence. Some of the psychotherapies that may be beneficial include (Gupta, 2022):

Behavioral therapy: Behavioral therapy is a phrase used to describe a wide range of therapeutic techniques that are used to change dysfunctional behaviors, eliminate unwanted behaviors, and learn to develop positive ones. The behavior(s) themselves are the issues to be addressed and new behaviors are encouraged to decrease or eliminate the negative issues.
Cognitive behavioral therapy: This therapy is designed to help people identify and change destructive behaviors.
Acceptance and commitment therapy (ACT): ACT emphasizes acceptance as a way to cope with negative feelings, symptoms, and/or situations. Simultaneously, ACT encourages dedication to healthy, constructive feelings and symptoms.
Psychodynamic therapy: Psychodynamic therapy focuses on guiding people to a deeper understanding of the emotions and gaining greater insight into their feelings and thinking processes.
Integrative therapy: This therapy incorporates techniques from different therapeutic orientations most appropriate to individual patients.
Systemic therapy: Systemic therapy’s foundation is examining how someone’s personal relationships and life choices are intertwined with situations that are faced in life.

Violence Alert! HOPE and RISE

Helping to overcome PTSD through empowerment (HOPE) is a form of therapy that is used to empower survivors who have developed PTSD as a result of domestic violence. Since the consequences of domestic violence include PTSD, it is important to note that HOPE is designed to address the needs of domestic violence survivors (Gupta, 2022).

Restore, Inspire, Support, Empower (RISE) is a type of therapy under development specifically for people who have had to deal with IPV. Already in use as a therapy for depression and anxiety for children and adolescents and facilitating co-parenting and dealing with divorce, researchers are now exploring RISE therapy as a means of specifically helping IPV victims (Gupta, 2022).

Prevention of Domestic Violence

Prevention is “stopping something before it has the opportunity to occur” (Pennsylvania Coalition Against Domestic Violence (PCADV), n.d.). While the concept of prevention may seem to be simple, that actual process of prevention can be both complex and challenging. Violence is a learned behavior. This behavior is learned from a variety of sources including parents, family members, caregivers, teachers, professors, communities, the media (including social media), and policies at the local, state, and national level. Violent behaviors must be unlearned and replaced with non-violent, more healthy behaviors. Ideally, children can begin their lives incorporating healthy behaviors and rejecting violent behaviors (PCADV, n.d.).

Media Influence

Negative Media Influence

The media’s impact on how society views violence is immense. Much of the media (including social media) normalizes violence, especially violence against females. Such normalization may contribute to the development and continuation of domestic violence (Investing in Women, n.d.).

An investigation conducted and published by the combined efforts of Unicef and UN Women (2022) analyzed the media reporting of violence against girls and the normalization of violence. Results helped to map the existing evidence of the relationship between media reporting of gender-based violence against girls and the normalization of violence. Highlights of the investigation include:

Mainstream news media outlets are inclined to incorporate destructive stereotypes when reporting events surrounding gender-based violence. This type of reporting tends to contribute to the normalization of violence as well as contributing to discriminatory gender norms and stereotypes.
Mainstream news media reports reinforce the factors that add to gender-based violence. These factors include victim blaming, promoting discriminatory gender norms, and stereotypes about the “appropriate” roles of females.
Evidence from scholarly literature shows that such literature often describes gender-based violence as periodic criminal incidents or independent occurrences of crime. Reports taken from such literature often use victim-blaming language and imply that victims have violated “traditional” gender rules and norms.

The news media, social media platforms, and pop culture often portray males and females in stereotypical ways, making males dominant and powerful, and women as passive, powerless victims of male sexual desires. Rape culture, as depicted by some of the media, reinforces the myth that females who are raped are “asking for it” based on the way they dress or the places they frequent. Examples of media portrayals that sexual aggression among males is normal and females are merely passive victims including the television series Game of Thrones (features multiple rape and abuse scenes), and the Netflix-released film 365 days (glamorizes kidnapping and rape). These types of media normalize, and even glorify, violent, abusive behavior (Lee, 2021). As long as this type of media is profitable, it will continue. It is up to the consumer to stop paying for films, streaming networks, etc. that contribute to the normalization of violence.

Violence Alert! Caution when Posting Online

Social media can be both a support for abuse survivors and a lethal danger. Consider the case of a young woman who was killed by her ex-husband after posting intimate details of their divorce on social media. By posting information about abusers and their abusive actions, perpetrators’ behavior may escalate dangerously. Experts recommend that victims think carefully before posting to social media and ask themselves, “Are these postings putting myself or my loved ones in danger if my abuser reads them? (Dzhanova, 2022). Healthcare professionals must also be caring when posting online, even personal, social posts. The slightest comment (e.g., “really frustrated today. Saw another lady who won’t leave her husband even though he beats her.”) may be used by abusers to track their victims or victims of friends whom they support.

Using the Media as a Prevention Tool

In 2017, the National Network to End Domestic Violence (NNEDV) created a guide as a resource for reporters and storytellers who report on domestic violence. “The goal of any story related to domestic violence should be to promote public health and safety by increasing understanding and awareness of the complex realities of domestic violence (NNEDV, 2017).”

Highlights of the guide include (NNEDV, 2017):

Any media reports related to domestic violence should promote public health and safety by increasing awareness and understanding of the realities of domestic violence.
Reporting on personal accounts of domestic violence must be done with compassion. Fact-checking stories can put the survivor in danger. If a survivor wants to remain anonymous, stories should be monitored to be sure that details that may identify survivors are eliminated.
Stories often concentrate on specific incidents (usually physical violence). It is important reporters make it clear that domestic violence includes a variety of abusive behaviors.
Specific domestic violence occurrences should be reported in the context of violence in the community and society in general. It should also be pointed out that domestic violence is a public health issue.
Reporters should acknowledge the roles that racism, misogyny, and structural inequality play in attitudes of viewing violence as “routine” and “normal.”
Domestic violence should not be reported in the context of the “two sides to every story” myth. Domestic violence is a crime, and the crime should not be mitigated by describing it as “one side of the story” or “accused needs a chance to clear their names.” Providing abusers with the opportunity to advance their stories (including “blaming” their victims) is to be avoided.
Reporters are encouraged to speak out about the impact of reporting on domestic violence on reporters, victims/survivors, and society.

Impact of Pornography

Pornography is one of the most rapidly increasing high safety-risk habits in society today. Research indicates that exposure to pornography is associated with perpetuating sexual aggression. Pornography tends to desensitize men towards women, which makes them view women as sex objects that exist simply to fulfill their sexual desires. Pornography can be seen as a prototype for behavior for some people. Adolescents in particular learn from and imitate behaviors presented in pornographic material. They may assume that victims actually enjoy sexual aggression (United We Care, 2022). Pornography also has an impact on members of the LGBTQ community since pornography can be targeted to persons of any gender orientation or sexual preference.

It is not only adolescents and adults who are exposed to and regularly view pornographic material. The average age of first pornography exposure is between 11 and 12 years of age, and this age is steadily decreasing. These young people may view pornographic materials as depicting what is “normal” and acceptable sexual behavior. Further complicating matters is that adolescent brains are in critical stages of development, which may make them more vulnerable to the impact of pornography (Glordiana, 2022).

Suggestions for helping adolescents deal with exposure to pornography include (Glordiana, 2022):

Parents and caregivers should have a conversation with their children at an early age about what they might see online and what to do if they see it.
The conversation should include the differences between pornography and consensual sexual activity.
It is recommended that to decrease the access to pornography, blocking and filtering systems are to be installed. The amount of time children use the Internet alone should be limited.
Parents or other caregivers must have frank discussions with their children about sexuality, healthy sexual behaviors, and the values that are part of the family structure. Discussions must be open, safe, and non-judgmental. Failure to have these conversations means that children will turn to others with their questions, which can exacerbate negative behaviors depending on whom the children consult.

Violence Alert! Acting as Role Models

Children and adolescents look to the primary adults in their lives to model the behaviors that they promote to their children. Children and adolescents are quick to notice when these behaviors contradict what they espouse as important (United We Care, 2022).

Focus on Abusers

Initiatives that attempt to prevent IPV by focusing on the abusers have had mixed results. Abuser reform was first discussed in the 1970s as IPV was in the process of becoming a crime. “Batterer intervention programs” concentrated on attempting to “unteach” patriarchal behaviors and values, which were believed to be the root of male-to-female violence (Pappas, 2023).

Most states mandate such programs for those individuals who are convicted of IPV. The most common initiative is the Domestic Abuse Intervention Project (Duluth Model), which is based on research conducted on male-to-female violence. This limits the applicability of the model to people involved in non-heterosexual relationship or those in transgender or nonbinary relationships. Unfortunately, the model has not been particularly effective (Pappas, 2023).

Alternative programs focusing on cognitive behavioral techniques have not been more effective that the Duluth Model. Abusers are typically treated with varying approaches to treatment with uncertain results. Because of these varied approaches, effectiveness of individual programs is very hard to determine (Pappas, 2023).

Currently, some research is being conducted on the effectiveness of Achieving Change through Values-Based Behavior (ACTV), which was created by Zarling and Lawrence and is based on the concept of acceptance and commitment therapy (an action-oriented approach to psychotherapy). This focus is on changing abusive behaviors. Early research findings suggest that ACTV may help abusers to control abusive behaviors (Pappas, 2023).

Potentially promising programs include Strength at Home (a competency-based therapy (CBT), that evaluates how someone’s own traumatic experiences can cause controlling behavior. Another promising program is Fathers for Change, a one-on-one approach. Mothers and children may be included as well (Pappas, 2023).

A Call for Change is another option that exists to prevent IPV. The program states that change requires long-term, daily, and often life-long effort and commitment. Its mission is to “prevent intimate partner violence by fostering accountability and change in people who harm or may harm their intimate partner. We do this by providing a free, anonymous, confidential helpline for people who use or at risk of using abuse and control in their intimate partnerships. The helpline is also available to family members, friends, and professionals who want to help someone stop using abuse” (A Call for Change, 2022).

A Call for Change is a “free, anonymous, and confidential intimate partner abuse prevention helpline (1-877-898-3411).” Helpline responders are not clinicians or counselors, but have been trained to view behavior, beliefs, and values of others with objectivity and understanding so that they can interact effectively with callers. Helpline respondents also provide information about other services and may make referrals to other programs as well (A Call for Change, 2022).

THRIVE

THRIVE (tool for health and resilience in vulnerable environments) is “a framework for understanding how community conditions impact health and a tool for engaging others to take action to improve those conditions.” THRIVE functions as a resource for involving community leaders, residents, healthcare professionals, and professionals across multiple sectors to improve community conditions that affect health (Minnesota Department of Health, n.d.). THRIVE is used in a variety of community organizations as part of initiatives to prevent domestic violence as well as to improve health, safety, and health equity (Prevention Institute, n.d.).

THRIVE was developed in 2002 and updated in 2011 by the Prevention Institute, a national nonprofit organization with the focus on building prevention and health equity into polices and actions at the federal, state, local, and organizational level (Prevention Institute, n.d.a.).

THRIVE and associated resources support communities through five steps to “improve health, safety, and health equity through a comprehensive, multi-sector approach to improving the community determinants of health.” These five steps (they are not linear but are reiterative and mutually reinforcing) Prevention Institute, n.d.b.):

Engage and Partner: Identify and engage the support of key participants and decision-makers, including diverse members of the community.
Foster shared understanding and commitment: Cultivate a shared understanding of the determinants of health and foster buy-in for addressing them as an effective, equitable approach to improving health and safety outcomes.
Assess: Identify the assets and needs of the community or neighborhood and its particular health and safety concerns and inequities.
Plan and Act: Clarify vision, goals, and directives; establish decision-making processes and criteria; and implement multifaceted activities to achieve desired outcomes.
Measure Progress: Ensure that communities use resources in the most effective, efficient manner, and that efforts accomplish the desired outcomes.

THRIVE promotes health by (Prevention Institute, n.d.b.):

Changing the way people think about health and safety.
Providing an evidence-informed, practice-based framework for change.
Developing community capacity while building on community strengths.
Facilitating links to decision-makers and other resources.

Concluding Statement

Domestic violence is a public health emergency. Healthcare professionals are obligated to recognize possible victims and intervene effectively. Intervention also includes follow-up and the provision of resources even if the possible victim decides not to press charges or chooses to return to the abusive environment. Healthcare professionals must be supportive, objective, and non-judgmental. Healthcare professionals are also obligated to participate in community efforts that prevent the occurrence of domestic violence. Healthcare professionals must work in conjunction with community leaders, healthcare consumers, and each other to promote a society that is devoid of domestic violence.

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Course Content

Introduction

Categorization of the Various Types of Domestic Violence

Violence Alert! Specific Forms of Abuse

Incidence and Prevalence Appraisal

Child Abuse Data

Older Adult Abuse Data

Marital Rape

Teen Dating Violence

Lethality

Comparison of Risk and Protective Factors

Risk and Protective Factors Related to Child Abuse

Individual Risk Factors

Family Risk Factors

Community Risk Factors

Individual Protective Factors

Family Protective Factors

Community Protective Factors

Risk and Protective Factors Related to Older Adult Abuse

Risk and Protective Factors for Teen Dating Violence

Violence Alert! Teen Dating Violence Prevention

Risk and Protective Factors for Intimate Partner Violence

Violence Alert! IPV and Pregnancy

Risk and Protective Factors for Domestic Violence Perpetration

Individual Risk Factors

Relationship Factors

Community Factors

Societal Factors

Violence Alert! Why Do People Become Stalkers?

Protective Factors

Critical Thinking Scenario # 1

Impact of Domestic Violence

Impact of Emotional Abuse

Impact on Children

Impact of Domestic Violence on Mental Health

Violence Alert! The Link Between Mental Health and Domestic Violence

Post Traumatic Stress Disorder

Negative Changes in Thinking and Mood

Violence Alert! Symptoms in Children

Depression

Violence Alert! Depression Symptoms in Children, Teens, and Older Adults

Generalized Anxiety Disorder (GAD)

Violence Alert! Association between Domestic Violence and Eating Disorders

Suicidal Ideation

Violence Alert! Impact of Cyberstalking on Mental Health

Impact of Domestic Violence on Physical Health

Violence Alert! Behavior Issues due to Domestic Violence

Critical Thinking Scenario # 2

Economic/Societal Impact of Domestic Violence

Analysis of Barriers to Reporting Domestic Violence

Fear

Lack of Supportive Family or Friends

Emotional Factors

Concerns for the Children

Financial Factors

Cultural/Societal/Religious Factors

Issues Concerning Male Victims of Domestic Violence

Issues Concerning the LGBTQ Community

Implicit Bias as a Barrier to Reporting Domestic Violence

Critical Thinking Scenario # 3

Recognizing Victims of Domestic Violence

Coercion and Threats

Intimidation

Emotional Abuse

Isolation

Minimizing, Denying, and Blaming

Using Children

Male Privilege

Signs and Symptoms of Physical Abuse

Signs in Children

Signs and Symptoms of Emotional Abuse

Signs of Sexual Abuse

Violence Alert! Victims of Sexual Abuse

Signs of Neglect and Abandonment

Reporting Domestic Violence

Violence Alert! Protection for Mandated Reporters

Failure to Report

Penalties for False Reporting

Critical Thinking Scenario # 4

Intervening when Domestic Violence is Suspected