Effective advocacy for domestic violence victims

EFFECTIVE ADVOCACY FOR DOMESTIC VIOLENCE VICTIMS Role of the Nurse-Midwife Leslye E. Orloff, JD ABSTRACT A nurse-midwife may be one of the first professionals domesticabuse victims talk to about the abuse. Like other health professionals who see abuse victims for health issues often unrelated to abuse, nurse-midwives have a special opportunity to identify, intervene, and support victims of domestic violence. Professionals working in health care will see abuse victims when they are living with their abusers and do not know that abuse is abnormal, when they attempt to leave their abusers, when they return to their abusers, and when they ultimately separate. Justice system professionals only see abuse victims when they have decided to try to leave. A thorough knowledge about relief available in the legal system for abuse victims will allow nurse-midwives to help battered women effectively. This article discusses the role nurse-midwives should play in assisting abuse victims who will be seeking help from the civil and criminal justice systems. Topics discussed include the importance of documenting injuries for use in future court cases, civil protection orders, criminal court prosecutions of the abuser, legal malpractice issues if health providers do not identify battered women, informing and referring domestic-violence victims, and the special needs of immigrant women. The article also discusses typical problems victims encounter in the legal system and ways victims can overcome these barriers.

Nurse-midwives and other health care professionals are uniquely situated to help abuse victims bring an end to the domestic abuse they experience. Health professionals are often the only professionals with whom abuse victims have continuing contact from the time before they learn that they may obtain help leaving their abusers, through failed attempts to leave, and after they survive the abusive relationship. Many battered women* become trapped in abusive relationships because abusers lower their victims' self-esteem and convince their victims that they deserve the abuse, that it is normal, or that no one will believe them if they seek help. For victims of domestic abuse, finding a way out of an abusive relationship is a difficult and dangerous journey because the risk of inAddress correspondence to Leslye E. Orloff, JD, Ayuda, 1736 Columbia Road, N.W., Washington, DC 20009. *Women, children, and men in countries and cultures throughtout the world suffer from domestic abuse. However, in cases of violence in adult relationships, over 9 0 - 9 5 % of the domestic violence cases victims are women (I). This article will use the pronoun "he" to describe perpetrators of domestic violence and "she" to describe abuse victims. In no way is this grammatical style intended to diminish the seriousness of same sex or female-on-male violence where the female is the primary perpetrator of domestic abuse.

jury and death dramatically rises once an abuse victim tries to end her relationship with her abuser (2). It is important that all professionals working with abuse victims understand that leaving an abuser is a process that begins when the victim first learns that what she is experiencing at the hands of her abuser is not normal, is criminal, and need not be tolerated. From that point onward, victims may begin to take what they have learned and move toward surviving domestic abuse. That journey usually includes several unsuccessful attempts to leave their abusers before they, ultimately, succeed (3). Professionals who are attempting to help abuse victims will seldom know exactly where the individual is on the survival continuum and must, therefore, offer consistent information and support all abuse victims encountered, whether this be her first or her last attempt to bring an end to the violence that she has been experiencing at home. Battered women who seek help escaping domestic violence may encounter shelters that do not have adequate space for them, friends and family members who do not believe them or who blame them for leaving and not keeping their families together, and a legal system, that is often well-meaning but where untrained employees apply "business as usual" methods of administering justice that are insensitive to the special safety needs of battered women and their children. There are major efforts underway throughout the legal system and in many communities to improve the understanding of judges, police, prosecutors, court personnel, and lawyers as to how the justice system can best assist abuse victims. Court procedures are being reformed; however, these changes have not yet uniformly reached the vast majority of communities in the United States. Despite this fact, battered women who persist in their efforts to seek help from the legal system, do ultimately obtain protection orders, criminal prosecution of their abusers, and custody of their children in the majority of jurisdictions. Those who succeed in obtaining legal relief must be persistent because they must overcome the many obstacles placed in their path by a legal system that is changing very slowly. Battered women's ability to obtain effective relief from the legal system is exponentially improved if they have support from caring professionals, friends, family members, or employers who offer them encouragement and assistance. Health professionals knowledgeable about the legal system and the obstacles battered women con-

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front within it are in a unique position to provide crucial information, support, encouragement, and referrals to victims and can vastly improve the abuse victim's chances of success. Battered women need midwives, emergency department staff, prenatal and primary care providers, and pediatricians who are trained to identify signs and symptoms of domestic violence and who routinely provide information, referrals, and support. This intervention on the part of health care professionals must send clear rues-

Leslye E. Orloff founded Ayuda's unique domestic violence program dedicated to serving the interrelated legal and social service needs of battered Latina and immigrant women and children. Ayuda's domestic violence program assists battered women in obtaining civil protection orders, divorce, child support, custody, immigration, housing, social services, day care, and any other services they might need to be able to flee batterers. Ms. Orloff has represented battered women and children in over 800 civil court domestic violence cases since 1983. She serves as a clinical supervisor to law students who come to Ayuda from programs across the country, and the majority of her most recent work focuses on offering domestic violence training to judges, police, probation officers, social workers, and health care professionals. She has written local and national training curricula and manuals for police, judges, and attorneys on domestic violence. In 1994, Ms. Orloff published a 400-page law review article analyzing civil protection order statutes, case law and practice in the 50 states, the District of Columbia, and Puerto Rico. Ms. Orloff serves as legal advisor to congresspersons, senators, state legislators, local governments, professional associations, and battered women's shelters on a broad variety of issues related to domestic violence and immigrant women. Ms. Orloff was a cofounder of the National Network on Behalf of Battered Immigrant Women and is the Washington, D.C., spokesperson for that organization. In that capacity, she was the primary drafter of the Protection for Battered Immigrant Women Provisions of the Violence Against Women Act. Ms. Orloff's current work included drafting amendments to proposed welfare reform and immigration reform legislation that will exclude battered women and battered immigrant women from many of those bills' harmful provisions. Ms. Orloff received her B.A. from Brandeis University in 1978 and her J.D. from the University of California, Los Angeles, in 1982. She is a bar member in California and the District of Columbia. She came to the District of Columbia to serve as a law clerk to Judge Gladys Kessler. She serves as a domestic violence, family law, immigrant women's, and Latino community expert for a variety of organizations and task forces, including the liaison to the American Bar Association's Commission on Domestic Violence, the D.C. Coordinating Council on Domestic Violence, the D.C. Courts Gender Bias Task Force, the D.C. Intrafamily Rules Committee, the National Women's Health Network, and formerly served on the D.C. Commission of Latino Community Development. In 1994, Ms. Orloff was awarded a fellowship from the Kellogg National Fellowship Program. With this fellowship, Ms. Orloff is undertaking a project studying women's economic development. Her project focuses on women and microenterprise, microlending, and entrepreneurship. She is studying photography and is interviewing women who are participating in microenterprise to learn how their participation in these programs has affected their lives and how they juggle multiple life responsibilities, including work, children, home, and community. Her Kellogg Fellowship lasts through 1997.

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sages that first, domestic violence is a crime, second, that abuse victims can receive help from the justice system and from battered women's advocacy programs, and third, and most importantly, that the nurse-midwife or other health care provider is willing to help support the abuse victim through the process of leaving her abuser and will respect her decisions whether she stays, leaves, or returns to her abusive partner. Health care professionals, particularly midwives, generally establish long-term trusting relationships with their patients. These trusting relationships make battered women more likely to disclose abuse and seek help and support from a midwife long before she might be ready to seek social services or legal relief. Most battered women and children in abusive relationships seek medical assistance several times for the consequences of abuse before deciding to seek legal or social services. The special relationship they develop with their patients offer nurse-midwives a unique opportunity to provide needed information and support to a population of abuse victims at heightened risk of abuse during pregnancy. The midwife may be the first, and only, source of ongoing support for many abused women and their children. Nurse-midwives, whether they realize it or not, often see women before and after they are abused and continue to see patients as they move through the process of revealing the v i o l e n c e : attempting to leave their abuser, returning to their abuser, and ultimately trying to leave again. Workers in the health care system are perhaps the on]y professionals who have regular contact with abuse victims at all stages of the abuse continuum. Consequently, health care professionals have a special responsibility to abuse victims to identify abuse early, provide what may be the first message that abuse is not normal or tolerated in our society, treat victims' injuries, offer referrals to legal and social services, and support the victim as she goes through what may be a lengthy struggle to leave an abuser. Nurse-midwives and other health c a r e personnel who provide services to a variety of patients are in a unique position to offer assistance to abuse victims who might not receive adequate assistance otherwise. When abuse is identified, it is important that al] victims, whether lowincome or wealthy, receive referrals to domestic violence service providers and shelters. These service providers are the experts on domestic violence in the community who can assist a victim in obtaining the services and legal assistance she needs. Battered women's advocates can assist wealthier abuse victims in locating family lawyers and mental health professionals who understand the dynamics of domestic violence and who have experience working with abuse victims. In this way, battered women will not fall prey to family lawyers or mental health professionals who are unskilled in working with abuse vic-

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tiros and whose interventions can often place the victim at greater risk. Most abused women in the United States--from all racial, class, and educational backgrounds--make two to five attempts to leave an abuser before they ultimately succeed (3). Battered women seek help from lawyers, police, courts, and shelters only when they are actively attempting to leave. Battered women drop out of contact with domestic violence service providers and the legal system when they return to their abusers out of frustration with the legal system for economic survival, because of legitimate fears of retribution and further violence if they refuse to return, or because they honestly believe his apologies and promises to change. However, most continue to seek treatment from health care providers for their pregnancies, gynecologic care, and children's health (4,5). Frequently, the midwife or the physician is the only professional with whom that abuser will allow the battered woman to have contact. Abusers allow this continuing contact because the nature of the professional relationship is unrelated to the abuse. For these abuse victims, the health care provider's office may be the only safe place they can go when they seek a break from ongoing violence. Midwives must be aware of this and must make patients aware that their office will always be a place where they can come to find safety.

violence and health. This resource center serves as a resource offering technical assistance to members of all health care professions working to improve the health care system's response to domestic violence. Working closely with panels of experts from the domestic violence community and a myriad of health professions, the Family Violence Prevention Fund, which runs the National Resource Center on Domestic Violence and Health, developed a model national training curriculum for health professionals on domestic violence. In Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers, the National Resource Center's model curriculum, Dr. Carole Warshaw states: If an injured victim of domestic violence is treated by a physician or nurse who does not inquire about abuse or who accepts an unlikely explanation of the injuries, and the patient then returns to the abusive situation and sustains further injuries, the physician or nurse could conceivablybe held liable for those subsequent injuries (7). Health care providers should be aware that, when working with family violence cases, there are four common instances where the health care provider may be open for liability if they act or fail to act in an appropriate manner. These include: 1) Reporting abuse to police without permission of an adult victim of abuse (6).

OVERVIEW OF POTENTIAL LEGAL LIABILITY FOR HEALTH CARE PROVIDERS IN DOMESTIC VIOLENCE CASES

Advocates working with abuse victims hope that training coupled with recommendations by professional organizations will be sufficient to change practices of health professionals who come in contact with battered women. Experience in training justice system professionals has demonstrated, however, that as is the case in society-atlarge, there will be those in any profession who cannot be convinced to offer the help they must to abuse victims out of compassion or because they wish to do what is right. Abusers, family members of abusers, and people who sympathize with abusers can be found in all walks of life. As nurse-midwives work in hospitals, clinics, and educational institutions to develop and implement protocols, practices, and policies that will make the health care system a place where battered women and children can learn about resources available to help abuse victims, there will be professionals within the health care system who will refuse to follow policies aimed at helping abuse victims. These health professionals should know that failure to follow accepted procedures with respect to domestic violence victims may leave the health care provider open to legal liability (6). In 1993, the U.S. Department of Health and Human Services set up a national resource center on domestic

It is well documented that the most dangerous time for an abused woman is when she has decided to leave her abuser (8). Women who leave their abusers assume a 75% greater risk of being killed by them (9). Fifty-seven percent of men who kill their wives are living apart from them at the time of the murder (I0). Battered women who have learned to thus far survive in an abusive relationship must be able to choose when to report abuse to authorities and when or whether it is safest to leave. Reporting about the abuse to police without the abused patient's permission will, in many cases, place her at increased risk of injury. Battered women must make this choice themselves. Health professionals should not substitute their judgment for that of the abuse victim. Health professionals who report information about victims of domestic violence to law enforcement authorities without the permission of an adult abuse victim (unless state statutes require them to do so) are violating patient confidentiality (11). Few states have reporting statutes because they increase risk of harm to the victim and they work against abuse victims by inhibiting their ability to seek health care out of fear that the abuse will be reported without permission (12). 2) Failing to identify victims of domestic violence (6). In recent years, the U.S. health care system has increased its sensitivity to the problem of domestic violence

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and its understanding about the important role health care providers can play in preventing domestic violence. Health care providers across the country are learning that they may be the only persons abusers allow their victims to see outside the home. For abuse victims who are isolated and alone, health professionals are often the first persons in a position to inform battered women that there are services available to assist them and that the victims may receive protection from the courts and the police (13). A battered woman can only embark on a path toward freeing herself from abuse when she knows that help is available. When health professionals develop and follow treatment protocols that include routine screening, identification, provision of information, and referrals to abuse victims, battered women can learn that what they are suffering is domestic violence and that the health professional can help them stop the violence. If battered women are not identified by health professionals, many will remain locked in violent relationships until the violence has become more severe. Health professionals should realize that they have the same obligation to identify and diagnose domestic viofence in the same manner as they identify and diagnose other health-related conditions. Most major health professional associations, including the American College of Nurse-Midwives (see editorial elsewhere in this issue for the American College of Nurse-Midwives Position Statement and Clinical Guidelines on Violence Against Women), the American Medical Association (14), the American College of Obstetricians and Gynecologists (15), and the Joint Commission on the Accreditation of Health Care Organizations, are urging association members to develop and implement protocols for identifying, treating, and referring domestic-violence victims. As these recommendations become standard practice by health professionals, the likelihood that a health professional will be successfully sued for not identifying domestic-violence victims who are their patients increases accordingly.* A victim may be able to sue successfully the *Kalsbeck v. Westview Clinic, P.A., 375 N.W.2d 861 (Minn. App. Ct. 1985); Brown v. Dahl, 705 P.2d 781 (Wash. App. Ct. 1985)

("reasonably prudent practitioner"; references in charge to jury to "average" and "ordinary" care improper). Culbertson v. Mernity 602 N.E.2d 98 (Supreme Court of Indiana 1992) (requiring evidence of what a "reasonable" physician would have done under the case's circumstances); Catron v. Bohn 580 So.2d 814 (Flo. App. Ct. 1991) (the plantiff must prove a breach of standard of reasonably prudent similar health care provider); Madlin v. Crosby 583 So.2d 1290 (Supreme Court of Ala. 1991); Hutchinson v. Paterl 637 So.2d 415 (Supreme Court of Louisiana 1994); Caughell v. Group Health Coop. Of Puget Sound 124 Wash.2d 217 (Supreme Court of Wash. 1994); St. John's Regional Health Ctr. Inc. v. Windier 847 S.W. 2d 168 (Missouri App. Ct. 1993); Jones v. Malloy 226 Neb. 559 (Supreme Court of Nebraska 1987); Shaw v. Caldor Inc. 1995 Super. Lexis 567 (Supreme Court Conn.) (The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment that, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by a reasonable prudent similar health care provider.)

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health professional who saw her and should have identified signs of domestic violence but did not and did not ask the patient about domestic violence. If that victim leaves the health professional's office and is reassaulted by her abuser, the health professional could become liable for damages arising from that assault. The victim could demonstrate that if she had been identified as an abuse victim, she could have learned that domestic violence usually recurs and becomes more dangerous over time and she could have taken steps to protect herself from the subsequent abuse. It is predictable that, in most cases, a victim of domestic violence will be abused again (16). By not informing her about domestic violence and the services available to help victims, the health professional may have contributed to her injury.* 3) Failing to provide information and appropriate referrals to patients who have been identified as victims of domestic violence (6). Once the health care professional diagnoses a health care problem, the provider has the obligation to provide the patient with information about that health problem and, if the health care expert is not a specialist in the particular problem diagnosed, refer the patient to experts (17,18). Health professionals have the same obligations and responsibilities to domestic-violence victims. Once the provider identifies that a patient is a domestic-viofence victim, the provider must provide the patient information about domestic violence and the resources available in the community to assist battered women. An abuse victim cannot make an informed choice about whether to take action to protect herself from continued abuse if she does not know what her rights and options are. Failing to offer abuse victims referrals to shelter programs and victim-advocate programs is akin to failing to refer a victim of any other illness to a specialist when the scope of the illness is beyond the expertise of the health professional. Only some battered women will follow up on the referrals the first time they are offered. Others will decide not to take the domestic violence information and referrals with her because she has no safe place to keep the materials and fears that her abuser might find them and retaliate. When patients refuse to take the information, health professionals should not be deterred for continuing to offer this information in the future. A health professional who respects the patient's right to choose when and whether to seek help because of domestic violence helps send a clear message to the abuse victim that the health professional's office is a safe place she can return to for help. *Scafidi v. Seiler 119 N.J. 93 (SupremeCourtof N.J. 1990); Thorn son v. S u n City C o m m u n i t y Hospital 688 P. 2d 605 (SupremeCourt of Arizona); DeBurkarte v. Louvar 393 N.W. 2d 131 (SupremeCourt of Iowa 1986); McBride v. U.S. 462 F. 2d 72 (9th Cir 1972).

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4) Failure to warn victims about the potential for assaults against them (6).

PROVIDING EFFECTIVE SUPPORTm UNDERSTANDING THE VICTIM'S EXPERIENCE

When a health care provider is treating an abuser, the provider may also be found liable for failure to warn foreseeable victims of the potential for future incidents of abuse. Courts across the country agree that this duty to warn goes into effect when the patient abuser presents a clear and present danger of harm to a specific victim or victims (19-21). Some states impose a duty to wam all persons who are foreseeably endangered by the abuser's conduct, with respect to all risks that make the conduct unreasonably dangerous (22). Failure to warn such victims about the potential for assaults against them can also lead to successful lawsuits by the abusive patient's victims against health professionals who could have informed them of the danger.

When nurse-midwives suspect that a patient is a victim of domestic violence, it is important that they understand the dynamics of that victim's experience so that they can provide the most effective support. Women in abusive relationships lose self-confidence after years of verbal abuse and her batterer relentlessly devaluing her. Abusers will cultivate the victim's emotional and economic dependence and will punctuate emotional abuse with episodes of violence that increase his power over her. A man who has perpetrated abuse in the past will add the threat of future violence to his emotional arsenal. All professionals who work with abuse victims must remain aware that leaving an abusive relationship is a process. There are many legitimate reasons why abused women return to live with their abusers. Battered women are survivors; they have learned to survive in abusive relationships. A patient may be afraid that leaving will be a triggering event for ultimate violence. The battered woman may have sought help from the legal system that did not respond swiftly enough, so she may return to the batterer as a coping mechanism to survive. The increased risk of violence following separation combines with an inability to survive economically to keep women in abusive relationships. Abusive men often keep their partners from working, attending school, and participating in job training programs. If she has a job, he will harass her at work, stand outside her window at work so that she cannot concentrate, or beat her and leave injuries in visible places so that she is too ashamed to go to work (31). Some women who do find work return to their abusers because they cannot earn enough to live in safe neighborhoods. They have traded known dangers at home for unknown dangers of the street (25). Batterers of immigrant women almost always threaten that the abuse victim will be deported if she leaves the violent relationship. Deportation is an omnipresent threat to immigrant women, regardless of their immigration status, because of distrust of the government, ignorance of immigration law, and deception by abusers. Among 64% of battered Latinas and 57% of battered Filipinas, the primary bar to social services is fear of deportation (33). If she is deported, she fears being sent to a country where her husband or his family members may harm her and that does not have laws to protect her (34). If she is forced to return, she may fear rejection by her family and community and blame for failing in her marriage. She may fear that deportation will permanently cut her off from access to her children who are U.S. citizens. Battered immigrant women often stay with their abusers and are reluctant use the legal system to end abuse because they fear the loss of custody of their children to their abuser. Many come from countries where children

UNDERSTANDING THE CYCLE OF DOMESTIC VIOLENCE

The central feature of domestic violence is the batterer's use of abuse as a means to control and gain power over the victim (23). Abuse may take several forms, including physical, sexual, mental or emotional, intimidation, threats, and manipulation. To strip her of her independence, the abuser will isolate the battered woman from family, friends, and community. He may control her activities, (ie, when and where she may go, whom she can see) and prevent or limit interactions with friends, family, and service and health care providers to decrease her access to information and support. He will abuse her economically to increase her dependency (24,25). He may prevent the abuse victim from obtaining employment, take away her money, and deprive her of access to family income and financial records. Most abuse victims also experience high levels of emotional abuse (26,27). The abuser will make the victim feel bad about herself, humiliate her, and destroy her self-esteem. He will instill fear in her by intimidating and threatening her. He may terrorize her with looks, actions and gestures, destroy her personal belongings, harm her pets, display weapons, or threaten to harm her, personally or through use of authority (ie, reporting her to the Internal Revenue Service or the Immigration and Naturalization Service) ( 2 7 - 2 9 ) . To justify his actions, the abuser will use male privilege and denial or blaming techniques. He may treat her as a servant, reserve all family and household decision-making to himself, not take the abuse seriously, and shift responsibility for the abuse to the victim (4,30). Through continued physical, mental, and emotional abuse, the batterer increases his control over his victim.

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are the legal property of their fathers. They do not know that our legal system has a preference toward awarding children to the nonabusive parent. Many immigrant women come from countries whose legal system is based upon a fundamentally different model, a civil system, rather than the common-law model used throughout the United States (35). Unlike the U.S. legal system, the system of her native country may not accept oral testimony as trustworthy evidence. Thus, she may think that no one will believe her if she goes to court and tells the judge what happened. She may come from a country where, as a matter of law, a man's word is worth more than a woman's. The judicial system of her native country may be an arm of a repressive government in which the person with the most money and closest ties to the government wins. These expectations about the legal system prevent a battered immigrant woman from seeking help unless she is encouraged and supported by an advocate or professional whom she trusts. Batterers of non-English-speaking women tend to isolate the victims from support persons from whom they might seek help by preventing them from leaming English and by preventing them from maintaining contact with friends or family members who speak their language. Language poses an additional barrier for battered women who tum to the legal and social service system for help escaping abuse. Few courts and police departments have available qualified interpreters on staff. Without the ability to communicate effectively in English, battered women who can not find help from bilingual advocates, or other bilingual professionals, have no access to protection from the courts (34). Few shelters offer multilingual hotline services or multicultural services. Shelters willturn away immigrant women because they have limited resources. Also, immigrant women often leave shelters because they feel unwelcome and uncomfortable in a new environment where staff and residents do not speak their language, eat familiar foods, or share their culture (34). For a broad variety of reasons, battered women may decide to stay with their abusers or may make several unsuccessful attempts to leave their abuser before they leave permanently. Nurse-midwives must keep in mind the difficulties women and children face who try to leave abusers and should not become frustrated by the victim's return to a violent household. Successfully escaping abuse is a process. No professional can know for certain at what stage of the continuum any particular abuse victim is when first encountered. Professionals should develop a relationship with each battered woman so that she will feel supported if she stays with her abuser, when she tries to leave, if she succeeds, and if she fails. Each battered woman must know that the door to the nursemidwife's office will always be open to her. It should be expected that many victims will be reluctant to discuss the violence because they are ashamed or

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because prior descriptions of the abuse to other health care professionals were ignored, were not believed, or produced inappropriate responses (36). To overcome this reticence, nurse-midwives should initiate the inquiry on the issue of domestic abuse. Even where the victim acknowledges the abuse, she may minimize the violence as a coping mechanism (36) or because she believes the violence is normal (37). Throughout the midwife's interaction with the victim, it is important to convey that domestic violence is wrong regardless of culture or community (38). The nurse-midwife should help the victim understand that domestic violence is a crime in all 50 states, the District of Columbia, and Puerto Rico (39). Violence may not be rationalized as normal within any particular racial, ethnic, or religious community, nor diminished because the relationship between abuser and victim is intimate. Despite claims that domestic violence is the norm in any particular woman's culture, it is no more a part of culture in any other country than it is part of the culture of the United States (40). ROLE OF THE NURSE-MIDWIFE IN THE LEGAL PROCESS Role of the Nurse-Midwife in Assisting Battered Women with Special Needs The health care professional will see women throughout the long process of leaving and will often be the victim's first contact beyond the forced isolation created by the batterer. The nurse-midwife can play a crucial role in assisting victims in escaping domestic violence by serving as a key source of support and as an advocate for victims who seek help from the legal system. Unlike social and legal service providers, the health care provider can be there to support the victims not only when they follow through in seeking out services but also when they do not. Many battered women will disclose abuse to a health care professional before seeking help from the legal systern. Upper-income women and immigrant women are two groups of women who are highly unlikely to seek legal assistance or social services on their own without the nurse-midwife's support and encouragement (41). Professionals in the justice system generally encounter greater numbers of abuse victims from lower-income families. This does not mean that abuse only happens in these families or that it happens at a much higher level than in upper-income families. Rather, turning to the justice system is the only option for many low- and middleincome families. Women from upper-income families may seek assistance in ending domestic violence from mental health professionals or from family lawyers, who may or may not be trained to help battered women effectively. In low-income and middle-income communities, where homes are closer together, neighbors often

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will call the police when they hear battering occurring. In wealthier neighborhoods, where homes are farther apart, reporting to the police more often falls solely on the shoulders of the abuse victim (41). There is, however, no evidence proving that abuse in wealthier families is any less severe. It is only better hidden. When more wellto-do victims do seek help from the legal system, they often encounter more frustrations and receive less assistance. It is extremely risky to assume that family lawyers unconnected with shelter programs are at all effective in assisting abuse victims; many profess to be, but most lack the technical expertise and supportive orientation needed to be effective. Few family lawyers who serve wealthier clients have any training in domestic violence; thus, settlements are made that can compromise the abuse victim's safety and frustrate her ability to leave. Upper-income women are also more likely than lowerincome women to tum for help to confidential resources, such as doctors, nurses, and mental health professionals, rather than police. Health professionals need training on domestic violence so that they can effectively help patients who are victims of abuse. Health professionals must be able to identify domestic violence and help victims access advocacy, counseling, and other services from professionals who have adequate training in domestic violence. For upper-income patients, these service providers can work together with their family law lawyers so that the battered patient is in a better position to receive the relief she needs from the legal system. Battered immigrant women are similarly unlikely to turn to the police and legal system for assistance. The intersection of domestic violence with immigration concerns pose a particular problem for immigrant women. Preliminary findings of a survey being conducted by Ayuda show that over three fourths of battered immigrant women married to citizens or lawful permanent residents are battered by their partners (42). Abusers who can provide lawful immigration status to their victims based on their marriage have traditionally used control over the victim's immigration status to lock her into the abusive relationship. The immigration provisions of the Violence Against Women Act were written to offer battered immigrant women married to citizens and lawful permanent residents an avenue of escape (43). Midwives who identify battered immigrant women who are married to citizens and lawful permanent residents of the United States should refer them for assistance to domestic-violence advocates and an immigration attorney who is experienced in representing battered immigrant women.*

*The national domestic violence hotline (800) 799-SAFE (7233), Ayuda (202) 387-0434 ext 20 or 33. and the NationalImmigration Law Projectof the NationalLawyer'sGuild(617) 227-9727 willhelp you finddomestic-violenceadvocatesand immigrationattorneysor advocates in yourarea.

Even a woman who has lawful permanent residency in the United States (ie, "green-card" holders) often fear deportation if she tries to seek help to stop the violence. Although there is nothing that the abuser can do to take away, or have taken away, a lawful permanent resident's or naturalized citizen's immigration status, lies by the abuser and fear of immigration authorities keep these victims under their abuser's control. Men who abuse immigrant women will steal or destroy their immigration papers or work permits so that they will have no proof that they have lawful permission to work in the United States. When working with patients who are lawful permanent residents or naturalized citizens, the nurse-midwife can reassure the patient that her lawful immigration status cannot be taken away by her abuser (41). Battered immigrant women have the same rights to obtain protection orders and seek criminal prosecution of their abusers as do all battered women. U.S. laws protecting the abused were written to offer the same protection to all victims without regard to immigration status. Undocumented battered immigrant women who need help should be referred to battered women's advocates for assistance in the same manner as you would refer other abuse victims. They may, however, require additional support and encouragement in leaving their abusers.

Critical Role of the Nurse-Midwife in Supporting Battered Women Who Seek Help from the Legal System The pre- and postnatal care provider can provide crucial support to a battered victim seeking to escape violence, by facilitating the victim's passage through the legal systern. Early intervention by a nurse-midwife can spur the battered woman's transition from violence. The most important roles for the nurse-midwife are identifying the domestic violence, documenting the abuse for subsequent legal proceedings (including civil protection orders [CPOs]), referring the victim to social and legal services, and supporting the victim through the frustrations she may encounter as she turns to police, prosecutors and the courts for help.

Identifying patients who are victims of domestic violence. Identifying characteristics. Hospital emergency rooms identify only 5% of the domestic-violence victims they see (44). Domestic violence has often been overlooked by health care professionals because the focus in health care is often the treatment of the injury rather than the cause. In a poll of its membership, the American College of Obstetricians and Gynecologists found that only 6% of its members asked patients about battering (45).

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Common characteristics of a domestic-violence victim seen in the health care setting are shyness, fright, embarrassment, evasiveness, jumpiness, passivity, and frequent crying. An abuse victim is often accompanied by a male partner who will refuse to leave her during the examination. If he agrees to leave, he will often listen immediately outside the door of the examination room. The male partner may answer inquiries on behalf of the patient, or she may look to him for permission to answer questions regarding her injuries. Observing the interaction between the patient and the person accompanying her can provide the nurse-midwife with important clues about whether the patient is in an abusive relationship. Health professionals who become adept at recognizing domestic violence can often detect patients who are victims of domestic violence by combining the medical history and their own observations. In addition to routine screening for domestic violence, health professionals should ask a patient about domestic violence anytime they suspect that she has been a victim. Asking the question reinforces for the patient that the health care professional is concerned about the violence and is a safe person to whom she can disclose violence and seek help. Identification of domestic-violence victims and early intervention can help prevent domestic violence by providing patient victims with information and a safe place to come for help. The earlier battered women learn that help is available, the sooner they will seek protection, reducing the need for treatment of future injuries by the health care provider. For a more complete discussion of identification of domestic-violence victims, see Bolin's article elsewhere in this issue.

Interviewing the abuse victim. When interviewing the patient, privacy is of utmost concern. A battered woman may be afraid to disclose information if she thinks the batterer will learn that she has talked about the abuse (46,47). Patients should be interviewed in private, away from children or companions. Accompanying persons should be told that office or hospital policy requires patients be seen alone. Nurse-midwives who have difficulty separating the patient from the persons who accompanied her to interview her alone can tell the patient that they need to take a clean-catch urine sample. The midwife will often be able to accompany the patient to the bathroom to help with the urine sample and can then privately ask questions about abuse and provide printed information if it is safe for the victim to take it with her. To help assuage the patient's fear that the abuser may discover her disclosure, the nurse-midwife should remember to inform the patient that all information provided is confidential and, under law, may not be disclosed to the batterer or anyone else (11). In the few jurisdictions with misguided laws that require health professionals to report cases of adult partner violence to law en-

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forcement authorities, the health care provider should inform the patient before asking questions about abuse that if the victim admits abuse, the health care professional may, under the law, have to report that information to the police. This disclosure will allow the patient to choose not to report abuse if she believes that involving police at that time is too dangerous.* Health care providers who work in states that have no mandatory reporting requirement for cases of domestic violence between adults should know that reporting information to the police or any other person without the permission of an adult domestic-violence victim could result in that health professional being held liable for breach of client confidentiality (11). Health professionals interviewing domestic violence victims should inform patients that domestic violence is a crime, that what she has experienced happens to many women, and that there is assistance available to help abuse victims. Nurse-midwives should also reassure an abused patient that they can offer assistance but that the victim has the right to choose whether and when she will seek help or attempt to leave. Nurse-midwives should also assure a victim that they are there to listen, support her whatever her decision, and offer a helping hand whenever she needs it. For a full discussion on how to work with patients who are reluctant to disclose abuse, see Chris King's article elsewhere in this issue.

Documenting the violence against the patient. Once the nurse-midwife identifies a patient as a victim or a suspected victim of domestic violence, the nurse-midwife should document the abuse in the patient's medical record. Good documentation in medical records of all incidents of domestic violence or suspected domestic violence will vastly improve the battered woman's ability to obtain effective relief from the legal system whenever she decides to pursue legal assistance. Documentation of abuse in medical records will help her obtain and enforce CPOs, obtain custody of her children, ensure that visitation is structured in a manner that is safe for herself and her children, obtain a divorce, keep the family home, receive an equitable distribution of marital property, receive an adequate amount of support, and have the abuser prosecuted for the crimes he committed against her. There are few *Adult abuse victimsare safest when they have the right to make informedchoicesabout when and whethertheywillleavetheir abuser or take other legalactionto stop the violence.Therefore,healthprofessionalliabilityarises when they interferewith the victim'sabilityto make informedchoices: i) when failureto identifydeprivesthe victim of informationabout the rights of domestic-violencevictimsand the names of organizationsthat could assist her, 2) when she is not informedby healthprofessionalstreating her abuser that she is in clear and presentdanger,and 3) whenabuseis reportedto policeauthorities without her knowledge(in states with mandatoryreporting requirements) or permission(in all other states).

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forms of documentation that are more helpful to victims involved in court cases than photographs and medical record entries made by health care providers. These records should be kept and routinely maintained whether or not an abuse victim is currently planning to pursue court action. For a full discussion of proper methods for documenting domestic violence in medical records, see the article elsewhere in this issue by Dan Sheridan.

Referring the patient to legal and social service providers. Nurse-midwives should identify resources in the community for abuse victims before an abused patient turns to them for help. Local shelter programs have experienced advocates who can assist battered women seeking legal assistance. Most can also help abuse victims identify trained lawyers who will represent them in court cases for free if the case involves complicated legal issues (custody or immigration questions) or the abuser hires an attorney. Even when the patient being referred is from an upper-income family, the best source of referral is the local domestic-viofence shelter or service program. Such programs have trained domestic-violence advocates on staff who are most familiar with the local judicial system's approach to domestic-violence cases. Shelter programs will also know the names of sympathetic family law attorneys who have been trained and have expertise in domesticviolence cases who could assist the patient in a protection order, custody, or divorce case. In developing relationships with domestic-violence service providers, it is also important to try to identify what services exist to assist domestic-violence victims from non-English-speaking populations in the community. In a few communities, the shelter may have bilingual, multilingual, or multicultural staff. Currently, in most communities, these services do not exist or are still in their infancy. To ensure that all abused patients in one's practice can seek the assistance they need, health care providers are urged to: 1) identify major language minority populations in the practice; 2) identify service providers (eg, immigration programs, church workers, social workers) in the community who work with these populations and who are willing to work together with others to offer assistance to non-English-speaking abuse victims; and 3) Plan a domestic violence training in which a local domestic-violence program or state coalition trains bilingual staff members and bilingual volunteers from your agency, along with staff members from other organizations working with immigrants with whom your agency wishes to coordinate services.

Providing emotional support for domestic-violence victims, Health care providers must work to develop a

trusting relationship with the patient in which she will feel comfortable talking about domestic violence. Patients will be more likely to answer questions posed about domestic violence honestly and accept the nurse-midwife's counsel if the relationship with the nurse-midwife is based on mutual respect and nonjudgmental discussion. The nursemidwife may be the battered woman's only link to battered women's services and counseling. In addition to developing resources for legal and battered women's advocacy services, nurse-midwives should develop a list of counseling programs in the community who are experienced in working with abuse victims. Family or couples counseling is inappropriate in domestic-violence cases and often leads to increased abuse. When batterers are ordered into family counseling with a victim, they are twice as likely to violate court orders by committing another crime than are batterers who are ordered into individual counseling (48). Battered women and abusive men should on ly be referred to state-certified counseling programs. Local shelter programs should be able to help a practitioner identify good programs. If none are available in languages other than English within the community, a local shelter might be encouraged to provide domestic-violence training for bilingual counselors working in the community. In the interim, an effort could be made to work with domestic-violence programs in the community to train volunteer translators who can help battered immigrant women participate in existing counseling groups. The nurse-midwife can successfully intervene by supporting the patient through what may be an emotionally difficult and frustrating process of leaving her abuser and seeking relief from the judicial system. Intervention should begin by letting the battered woman know that the nurse-midwife is concerned about her, that the woman is not alone, that she does not deserve the abuse, and that help is available (49). By taking the woman's experiences seriously, without minimization, the nursemidwife will help the abused patient understand that she has the right to respect and to be treated in a nonabusive manner. The perinatal health professional is in a particularly good position to empower an abuse victim to make her own decisions. This approach builds the patient's self-esteem and helps move the abused patient through making a decision to escape the violence and visualizing a life apart from the abuser. This visualization is critical to the abuse victim's success in separating from her abuser. Listening carefully to the abuse victim's needs, concerns, and fears, the nurse-midwife can identify both the patient's barriers to stopping the abuse in her life and the types of remedies she will ultimately need to seek from the court system. Asking questions of the victim, listening

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carefully to the responses, and supporting an abuse victim's decisions not only helps empower the victim but improves the nurse-midwife's ability to assist the victim in a culturally competent manner. Abuse victims should be asked what they need and what the barriers are to their taking action to stop the violence in their lives. Victims will answer from their own life experience. In doing so, they identify their needs in their own cultural context. A health care professional must take care to listen to the battered woman's needs and should avoid the temptation to "treat" the problem by telling her what she should do, by telling her the shelters into which she should move, or by telling her the services she should access. Telling abuse victims what they should do and judging them based on how well they followed instructions re-creates in the health provider/patient relationship the same power dynamic as that which she experiences in her relationship with her abuser. All professionals working to help abuse victims should be sensitive to this issue and work hard to help patients in ways that build their self-esteem. UNDERSTANDING THE LEGAL FRAMEWORK FROM WHICH THE PATIENT MUST SEEK RELIEF

Nurse-midwives need to understand the legal system so that they can explain to patients what the legal system can do for them, how it works, and what patients might expect if they seek assistance from the justice system. They can help the woman anticipate problems and frustrations that may arise when the patient seeks the assistance of police, prosecutors, lawyers, and judges. By being aware of common problems, the nurse-midwife can either work in advance to minimize those obstacles or prepare the battered woman on how to overcome difficulties as they arise. The battered woman may be involved in the civil or criminal justice system or both. Civil Protection Orders

Issuance. Civil protection orders can be obtained on the initiative of abuse victims in any state, the District of Columbia, or Puerto Rico (50). Civil protection orders are an important tool in protecting battered women and their children. Protection orders are a special type of court order that tells the defendant/batterer not to harm the victim again. They warn the abuser that he will suffer criminal penalties if he violates the order or harms the victim in the future. Civil protection orders are only available to help victims of domestic violence. When properly drafted and enforced, protection orders are effective in many cases in eliminating or reducing domestic violence (51). Protection orders are civil court orders issued by a family or civil court judge. Prosecutors and the state are not involved in the issuance of protection orders. How-

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ever, violation of most provisions of a CPO is a crime prosecuted in the criminal courts or prosecuted by the victim or the judge as contempt of court. Victims can obtain protection orders whether or not there is a criminal case against their abuser (52). A protection order can be requested without filing for divorce or after a divorce or custody order has already been issued. In some states, protection orders can be entered as part of a divorce decree. Abuse victims may file for a protection order at any time. There is no particular amount of time after a violent incident occurs within which a victim must file for relief, although emergency temporary protection orders are only issued when there is imminent danger of abuse. No court fees or costs may be charged for the filing of a CPO (52). Most CPO court procedures were designed to help ensure that abuse victims could obtain protection orders simply and easily without the assistance of a lawyer. Research has found, however, that battered women get more protection orders and orders that contain better relief if they go to court with the assistance of a lawyer or an abuse victim's advocate (51). Court procedures can be confusing for women trying to obtain a protection order on her own. Although court clerks in many states are helpful in telling women what forms to fill out and how to fill them out, some states do not allow clerks to provide this information. More and more jurisdictions are reforming their court procedures to make CPOs more accessible to victims who must seek them on their own. Some courts have special hours set aside for people representing themselves without the assistance of an attorney. The nurse-midwife can alleviate the abused patient's fears and uncertainties about the legal system by understanding the basics of the legal process and explaining the system to the patient considering legal protections. Health professionals can help battered women who will be seeking protection orders think through what relief they should request from the court (52). The patient should be asked what she needs to make her safe. If she will be leaving her abuser, does she wish to remain in the house? Does she want custody of her children? Will she need child support? The provider should work with her to identify her fears and concerns and then to create a list of remedies that could be included in a court order to address each of those concerns. Under most state statutes, courts can include in a protection order any relief that is warranted, that is likely to help stop violence, and will resolve ongoing disputes between the abuser and his victim. The more complete this list, the more likely the CPO will be effective in stopping violence. This list of remedies the patient would ideally like to receive from the court will be helpful to her if she will be getting a protection order on her own and will also be helpful to the victim's advocate or lawyer assisting her.

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W h o can get a civil protection order? Almost all states, including the District of Columbia and Puerto Rico, will grant CPOs to stop violence by spouses and former spouses (53). Similarly, almost all states, including the District of Columbia and Puerto Rico, will grant CPOs to stop violence by nonspouse family members (ie, siblings, stepsiblings, parents, stepparent, and in-laws) (54). Federal Bureau of Justice Statistics research indicares that violence at the hands of a nonspouse family member may even be more common than violence by current spouses (55). A majority of states and the District of Columbia will issue CPOs on behalf of minor children of one or both parties (56). A battered woman's protection order can include protection for her children, whether or not the children have been directly physically abused themselves (57). Growing numbers of states are also offering protection to friends and relatives of the victim who have not been abused themselves but who may be offering refuge to the abuse victim (58). Attorneys for battered women have also succeeded in obtaining protection orders requiring the abuser to stay away from the offices of service providers and health professionals who assist the abuse victim. If this protection is needed, the addresses to the specific locations from which the abuser must stay away should be listed in the order, and the victim should provide each office a copy of the order so that office staff can use it to show the police if necessary. A great majority of states and the District of Columbia will issue a CPO to stop violence between unmarried intimate partners who live together (59). These orders are generally available to offer protection in gay and lesbian relationships (60). Civil protections orders are also intended to protect against abuse by a batterer who shares common children with his victim, regardless of the marital status of the parties (61). However, the law is unsettled as to whether a CPO will protect the abuse victim when the victim and the abuser do not live together and the woman is pregnant with the first child from that relationship. As essential as protection orders are for this class of victim, some states have not recognized this relationship for coverage under their civil protection laws. To address this problem and to reach a significant population at risk of abuse in intimate relationships-namely, teenage dating violence--a growing number of states, the District of Columbia, and Puerto Rico now offer protection orders to victims in dating relationships with their abusers. All family violence victims can obtain protection orders, even those who will continue living with their batterers (52). Protection orders issued when couples still live together order the abuser not to molest, assault, threaten, harass, abuse, or intimidate the victim and may order the abuser into a batterer's counseling group. Battered women who have obtained these orders report that

the orders helped shift the balance of power and control in the relationship and, for the duration of the order, significantly reduced or eliminated violence. For many, the order provided the victim with a period of relative calm in which she could begin to envision and plan for a life apart from her abuser (52). All state CPO laws allow competent adults to file for their own CPOs. An adult domestic-violence victim's protection order may also protect the children. In cases where a violent act has been perpetrated against a child, a nonabusing parent or guardian may file a protection order on the child's behalf against the family member who abused the child. Protection orders on behalf of children may be filed whether or not the state social service agency is taking action against the abuser for child abuse. Battered women whose children have also been abused should be encouraged to obtain protection orders for themselves and for their children so that they will be able to demonstrate to the court that they are taking steps to protect their children from continued abuse; this can prevent the state from taking away their children for "failure to protect" (52). W h e r e can a protection order be filed? Protection orders are generally granted and enforced where the incident of domestic violence occurred; where the abused person lives, works, or is at continuing risk of abuse; or where the perpetrator of abuse resides. Victims who are in hiding may prefer to file for an order of protection where the abuser resides to keep her address a secret. Victims contemplating filing for protection in the community where the abuser resides may need to assess the safety of filing there. Under the Violence Against Women Act that became law in 1994 as part of President "Clinton's Crime Bill, protection orders issued in one state, town, or community must be enforced in any state or community at any location in the United States. The state to which the abused woman flees must enforce the order without changing any of its provisions. That order must be enforced even if the order or some of its provisions could not have been issued as part of a protection order in the enforcing state. The state must enforce the order in the same manner that it enforces its own protection orders. Health professionals should be aware that this is a new law, and few states or communities have experience enforcing orders from other states. Orders are enforceable if court papers were filed, notice was served, there was an opportunity for a hearing, and the court issuing the order decided that the victim was entitled to the order because the abuser committed one or more violent or criminal acts against the victim. "Mutual" protection orders are prohibited and unenforceable (62). Mutual orders are orders that are issued against the abuser and the victim in a case that the victim

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filed in which the abuser never filed any papers in a separate action against the victim. Petitioners who act in selfdefense and injure their abusers doing so are generally found not to have committed domestic violence against their partner. Good medical records that clearly record petitioner's injuries as defensive often offer critical support for abused women who must assert self-defense claims. What crimes can support the issuance of a civil protection order? Almost any criminal act or attempted criminal act can be grounds upon which to base a CPO, including physical abuse, trespassing, kidnaping, malicious mischief, and reckless endangerment (63). Violence in the home has not, historically, been treated as seriously as violence committed by strangers. However, if all domestic-violence cases were reported to law enforcement authorities, one third of all domestic-violence cases would have been charged as felony assaults or rapes (64). The rate of injury in assaults by spouses and former spouses is over twice the injury rate for assaults by strangers (65). The most common criminal act on which CPOs are based is battery. Battery includes a number of actions, including striking, hitting, beating, choking, or kicking the victim; pulling the victim's hair; throwing the victim against a wall or floor; using weapons, including knives, guns, and trained dogs to attack the victim; and punching a pregnant victim in the stomach. Violence directed at third parties can also be basis for issuance of a protection order, including assaults upon the victim's friends or family (63). Civil protection orders are also issued when the abuser interferes with the liberty of the victim--restraining the victim, stalki~g the victim, breaking into the victim's home, and pulling the victim from her car (63). Sexual assault and marital rape will also result in the issuance of a CPO (66). Threats are also acts of domestic violence and are criminal acts that will result in the issuance of a CPO if they place the victim in fear for her safety (67). Examples of such threats include threats of physical violence and arson, threatening to get the victim fired from her job, and threats of property damage. Intimidating threats, such as leaving a shredded marriage license or tomato juice-stained clothes on the victim's doorstep, have also served as grounds for a protection order. Seventeen states also recognize harassment as a basis for a CPO (68). Harassment is understood to encompass a wide range of actions, including isolation of the victim, interference with the victim's life, making frequent and unwelcome telephone calls, loitering near the victim's residence, opening the victim's mail, meeting with the victim's friends and dates, and screaming and cursing at a victim from outside her home.

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Relief available through a civil protection order. When issuing a CPO, courts may order any relief that is likely to eliminate or reduce violence between the parties (52). Victims need to request from the court all the relief they need, including that which goes beyond what might be typically ordered. This approach reduces the chances of receiving an ineffective order. The most effective orders are those that address all potential areas of continuing conflict between the victim and the abuser. By helping victims create lists of the relief they need, nurse-midwives can help ensure that women get more effective protection orders. Although there are certain forms of relief that most abuse victims will need (ie, granting exclusive possession of the family home to the victim, granting the victim custody of the children, ordering child support, ordering stay-away and no contact orders), there will be other forms of relief needed that will be specific to the individual case (see Appendix A). Examples of creative forms of relief might include ordering the police to confiscate the abusers weapons (69), prohibiting abusers from interfering with the victim's immigration case or ordering that the judge and both parties sign statements prohibiting issuance of a visa to the U.S. citizen's children for travel abroad as a means of combating international child snatching. Health professionals should also identify domestic-violence victim advocates in the community who can accompany victims to court. How to get a civil protection order. In filing for a protection order, battered women must first decide if they need to receive the immediate protection of a temporary protection order. Battered women who have recently experienced a violent incident and who often still have visible injuries as a result of the abuse typically initiate the protection order process by filing a temporary protection order. Women who feel they need protection but do not need to receive an order within 24 hours of filing with the court will file directly for a CPO and will usually receive a hearing on their CPO case between 2 weeks and I month after filing their papers with the court. Temporary protection orders. When a battered woman has recently suffered an incident of violence and/ or is in imminent danger of abuse, she can seek an ternporary protection order. Temporary protection orders are available in many states 24 hours a day. This form of protection can offer significant immediate relief for battered women in crisis. As a general rule, any woman who has suffered physical injuries can easily obtain a temporary order. The temporary protection order is issued without the abuser being present or receiving notice of the hearing. Forms that can be used by abuse victims to file for temporary protection orders are available from the local courthouse. Court clerks or advocacy programs

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for domestic-violence victims can assist victims in completing the forms. Temporary protection orders are of short duration, 14-30 days, and must be served upon the abuser to be enforceable. To obtain protection for a longer period of time, the victim must return to court for a CPO hearing. Nurse-midwives should be cognizant of the fact that many abuse victims are unaware that once they obtain a temporary protection order they must return to the court to receive the more permanent protection order. It is important to follow up with patients to make sure that they attend this very important second court hearing. The temporary protection order is issued based on the petitioner's affidavit or testimony and can provide different types of relief to the victim (see Appendix B). To obtain a temporary protection order, the abuse victim must present to the court facts that demonstrate that she believes she is in immediate danger of harm from the abuser. To obtain a nonemergency CPO after the abuser has received notice of the hearing, the standard is considerably less. The victim need only prove by a preponderance of the evidence (that is more likely than not) that the abuser committed a criminal act or other act prohibited by the statue against her (ie, harassment or stalking).

Obtaining a civil protection order. Battered women and children can apply for CPOs by filing a petition with the local court. In that document, the victim must relate a history of abuse; in some states, she will be required to tell the court what relief she will be requesting. Court forms often only have enough space to list one or two violent incidents, but victims should use additional pages to list the complete history of abuse. When the abuse victim files her papers requesting a CPO with the court, she will receive a copy of her petition for herself and a second copy will be forwarded to the sheriff's office or other law enforcement agency to serve on her abuser. In many jurisdictions the victim may also request an extra set of papers that she can have a process server, friend, or family member serve on the abuser. The victims should provide the police or the process server with information about when and where they would be most likely to be able to serve the abuser. One of the safest places to serve abusers in at work. If the abused person requesting a CPO does not attend the hearing, the court cannot issue a CPO. However, if the abuser who had been served with notice does not attend the hearing, a judgment can be entered against him by default so long as the victim is present at court to present evidence. Civil protection order hearings are held before judges without a jury. At the hearing, the battered woman or child will get her or his protection order if she or he demonstrates evidence sufficient for a protective order to be issued. Protection orders can be entered based on the

victim's uncorroborated testimony alone, but relying on the victim's testimony only can be risky and often affects the quality of the relief the court orders. It is best if the victim can corroborate her testimony about the violence with photographs, medical records, police reports, and testimony of witnesses to the violence or to injuries caused by the violence. If the court believes that an act of violence occurred, the court will issue a protection order offering the victim protection for a specified time period. In some progressive states, protection orders last indefinitely (52).

Instructions for victims who have received protection orders. Battered women should obtain from the court several certified copies of her temporary or permanent protection order before she leaves the courthouse. She should carry one copy with her at all times. Other copies should be left at her place of work, her relatives' homes, and other locations where she spends time (52). If her order grants her custody or has specific visitation provisions, a copy of the order should be given to the children's school or day care center, so they can call the police if the batterer attempts to abduct the children. It is also a good idea to file a copy of the certified order at the police stations located near her home and her work so that they may respond more swiftly to crisis calls. Permanent family court cases for patients with protection orders. Although CPOs are a very useful tool to protect battered women, they generally do not last long enough to offer permanent relief to battered women. To obtain permanent relief and fully resolve outstanding legal issues with her abuser, battered women will need to file for divorce, legal separation, custody, and/or child support with the local court that hears family matters. Family court cases are difficult for abused women to pursue on their own and require the assistance of a lawyer. Health care professionals should understand that unless the abused victim follows up her protection order with a family court action, her custody and child support orders will disappear when the CPO ends. Health professionals should work together with shelter advocates to help battered women secure permanent orders from a family court. Civil protection order enforcement. Protection orders are not self-enforcing. A battered woman must be willing to call the police to initiate a criminal prosecution and/or file additional court papers in a criminal or civil contempt action to enforce her protection order if the batterer violates any of the order's conditions. In virtually all states, violation of a protection order is a misdemeanor. In a few states, violations of at least some of the provisions of a protection order is a felony. The 1994

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Violence Against Women Act made it a federal felony to cross state lines for the purpose of violating a protection order. It is important to know that police are more likely to protect a battered victim when they are called to the scene of a domestic-violence incident if the victim has gotten a protection order and shows it to the police. Civil protection orders work best in jurisdictions where police consistently enforce protection orders and arrest for violations (52,70). Protection orders remain in effect until they expire or are modified by a subsequent court order. Reunification of the abuser and the victim does not nullify an existing protection order. Civil protection orders issued by the court against the abuser and the victim cannot invite or excuse the abuser's violation of that order. Unless another court order is issued that rescinds or modifies the protection order, the abuser is responsible for complying with that order. Reunification of the parties after a protection order has been issued does not excuse the batterer from obeying the order's requirements that he not abuse the victim. Although the defense of reconciliation has not been recognized by courts, reunification may affect how the abuser will be sentenced for having violated the court order.

Criminal justice system enforcement of protection orders. A battered woman may call the police and have her abuser arrested when he has violated her CPO. The police can arrest the abuser if they have probable cause to believe that he violated the order, whether or not the violation occurred in the officer's presence. Whether or not an arrest is made, the battered woman should insist that the officer take a police report and she should get the name, badge number, and phone number of the ofricer who responded to her call for help. The criminal prosecution is initiated by the police and the state prosecutor. It is an action between the state and the abuser in which the victim is the state's witness. The state prosecutor controls case strategy. The ultimate goal of the criminal prosecution is to punish that abuser for his violation of the court order. The abuser usually is not held in jail while the criminal action to enforce the protection order is being decided, but he can be ordered to serve jail time and be placed on probation if he is convicted.

Criminal contempt of court. The victim can bring a criminal contempt action to enforce her protection order whether or not the state is pursuing a criminal case against her abuser for violation of her CPO (71). If the abuser is found to have violated the CPO, he can be jailed and/or fined. To win a criminal contempt case, the victim must prove beyond a reasonable doubt that the abuser has violated the CPO. This is a difficult standard for victims to meet without the assistance of legal counsel. Therefore, it is particularly important that health pro486

fessionals help victims who need to enforce their protection orders find attorneys and domestic-violence advocates who will help them. When a criminal contempt action and a criminal case brought by the state proceed simultaneously, it is important that the cases be coordinated. The criminal contempt case is a court action between the victim and her abuser. The victim controls the conduct of the case, and sentencing can include relief that addresses her specific safety needs. The contempt action can often be decided sooner than the criminal case. The contempt case can provide the victim with much-needed protection by either placing the abuser in jail or on probation while the criminal case is being decided.

Civil contempt of court. When the abuser has viofated provisions of a protection order that require him to pay child support, spousal support, or other monetary relief, the petitioner can enforce these provisions of the protection order by asking the court that the abuser be found in civil contempt of court. Civil contempt is also appropriate when the abuser fails to vacate the home or turn property over to the petitioner. The goal of civil contempt is to coerce the abuser's compliance with court orders. By contrast, the goal of criminal contempt or criminal prosecution is to punish the abuser for not complying with court orders. Problems abuse victims encounter as they seek legal relief. When a battered woman turns to the legal system for help, she encounters a system that is far from perfect. If police, judges, attorneys, and court personnel have received any domestic-violence training, they have done so only recently. Few have significant experience helping battered women. Often, even those justice system professionals who want to help lack the understanding about the dynamics of domestic violence they need to intervene in a manner that will be truly helpful to abuse victims. Health professionals are specially situated to offer continuing support to abuse victims who are attempting to obtain legal relief. They can help victims understand some of the hurdles they encounter in the legal system and provide information needed to encourage victims to persist in their efforts to obtain legal relief. Providing information can help victims overcome their frustrations with a legal system that is often slow, bureaucratic, and seemingly uncaring. Typical problems that victims face include: 1) T r y i n g to obtain a protection o r d e r on her own.

Most courts provide access to protection orders for victims who seek orders on their own. It is always better for victims to obtain protection orders with the assistance of domestic-violence victim advocates or

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2)

3)

4)

5)

attorneys who are familiar with the court system and the judges who issue the orders. Nurse-midwives should identify organizations within their community or state who assist battered women in obtaining protection orders and should participate in trainings with those groups to learn more about relief available to victims in the community. The abuser arrives in court with counsel. Many times, a victim who does not have an attorney to represent her will come to court and have to seek a protection order or handle a family court matter when the abuser is represented by counsel. In such cases, it is essential that the woman be assisted by the health professional to contact a local domestic-violence program that can help the victim locate counsel. Few battered women are able to obtain the legal relief they need when they must take on an abuser who is represented by counsel alone. This is particularly true in contempt actions to enforce the CPO. Continuances are one tactic that abusers use to manipulate the court system and obtain an advantage over their victims. Abusers will request repeated continuances of CPO cases and family court cases to delay the issuance of child support awards, to get the victim to drop the case and return to him, or to make her lose her job because of repeated absences due to court appearances. She should oppose continuances and should understand that they do not mean that the court will not ultimately give her the relief she is seeking. Health professionals can encourage her to follow through with the court case. They should also help stave off problems with her employer by obtaining the victim's permission to call her employer and explain the victim's need of time off to appear in court. Victims must act to enforce protection orders. Protection-order enforcement usually requires that the victim calls the police to report violations and cooperates in criminal prosecution. The victim must file and prosecute contempt actions herself. Battered women who are willing to act to enforce their CPOs need strong support and encouragement from people they trust. Health professionals can offer an important source of support to victims who are struggling to ensure that the law protects them. Batterers often test the strength of protection orders by first violating "stay-away" and "no-contact" provisions. If they can violate these provisions and go unpunished, they will move on to more serious violations. Health care providers can help victims think through enforcing orders when violations begin, rather than wait until violations escalate to new assaults on the victim. Family lawyers untrained in domestic-violence law often urge victims to agree to keep issues of domestic violence out of divorce, custody, and support cases. When a domestic-violence victim needs to find

a family lawyer to assist her, the local shelter program is usually the best source of referrals to family lawyers who understand the legal rights of battered women. If an abused woman obtains a family lawyer from another referral source, the health professional can assist by informing her that it is not in her best interest to agree to "stipulations" that keep facts of domestic violence out of her family court case. Evidence about the history of abuse is important for custody decisions, division of property, and spousal support. If her lawyer asks her to sign a "stipulation" to agree not to tell the court about the violence or wants her to agree to mediation, the health care provider should urge her that she should call a local shelter program for a referral to a lawyer who can offer her a second opinion about how she should conduct her legal case. Mediation is not appropriate in cases where there has been a history of domestic violence. 6) Obstacles for battered immigrant women in obtaining protection orders. Language poses one of the largest barriers to protection for non-English-speaking women. Few courts have bilingual staff, bilingual court forms, or interpreters available. Nursemidwives who are bilingual or who have bilingual staff in their programs can assist battered women in gaining access to the courts. Alternatively, nurse-midwives can work with advocates for abused women to identify and train a core of volunteers who can assist with translations. Fear of deportation deters many battered immigrant women from seeking protection orders. They fear any interaction with the government, but they need to be reassured that they can receive protection orders without risking deportation or jeopardizing their immigration status. Protection orders are essential in equalizing the balance of power in abusive relationships, and they work particularly well in immigrant families.

Criminal Justice System The U.S. criminal justice system is moving toward treating domestic violence as a crime. It has become apparent that one of the most effective ways to force abusers to stop using violence in intimate relationships is to raise the social costs of committing crimes at home behind closed doors. These crimes must be treated as all other crimes. Abusers should be arrested for these crimes in the same manner as all other criminals. The key goal of the 1994 Violence Against Women Act was to improve our criminal justice system's approach to arresting, prosecuting, convicting, and sentencing abusers. In a criminal domestic-violence case, the abuser is charged by the state with a crime. The goal of the criminal prosecution is to punish the abuser for his criminal actions against the victim. All of the criminal acts that

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serve as a basis for issuance of a CPO can also be simultaneously prosecuted in the criminal courts. Crimes may also include failing to stay away from a former spouse, entering the victim's residence in violation of a protection order, and violating other terms of the protection order (72). Once prosecutors have decided to bring a criminal case against an abuser, they may also charge him with crimes he committed at an earlier date against the same victim. Crimes may be charged as felonies or misdemeanors, and various different crimes committed over a period in the abusive relationship may be tried together. Criminal domestic-violence cases usually begin when an abuse victim calls the police for help during an abuse incident. In virtually all states, when the police arrive on the scene of a domestic-violence call and see evidence that gives them probable cause to believe that a crime has been committed, they may arrest the abuser without obtaining a warrant even if they did not see the abusive incident happen. In the majority of states, the police are mandated to arrest the abuser in those cases, even if the victim requests otherwise (73). Domestic-violence victims may call the police to report abuse and have their abusers criminally prosecuted by the state for the abuse committed against family members. A criminal prosecution and a CPO case may proceed simultaneously or at different times. Criminal cases can be effective in deterring domestic violence because they send a clear message to abusers that there will be legal and social consequences if abuse continues. The criminal prosecution, however, offers the victim little relief aimed at her particular needs, and any protection the criminal case offers ends when the case is over or when the abuser has served his sentence. For this reason, it is always advisable that battered women whose abusers are being criminally prosecuted also obtain protection orders. The victim controls a CPO case and can have some control over the enforcement of the CPO. In contrast, the victim is a witness in the criminal case and does not control the criminal case. The criminal domestic-violence case is between the state and the abuser who has perpetrated a crime against the victim. Model criminal court practice in domestic-violence prosecutions is currently based on a strong relationship between the police who investigate the domestic-violence cases and the state prosecutors. The goal of these prosecutions is to gather sufficient evidence and statements at the scene of a domestic-violence incident so that the criminal prosecution can go forward without requiring the victim's cooperation. Model criminal court practice makes it clear to abusers that the criminal case is between the state and the perpetrator; the abuser's actions to intimidate the victim, or to try to convince her not to cooperate, will not prevent the criminal case from going forward. This ap-

488

proach holds abusers accountable for their actions and improves safety for victims by not requiring them to testify if they are terrified by retribution from their abusers. It also places control of the case squarely in the hands of the state, whom the abuser cannot control. Unfortunately, too few state and local prosecution offices and police departments have been trained in domestic violence sufficiently for this practice to become the norm nationwide. In many parts of the country, domestic-violence victims still retain some modicum of control over whether or not a criminal prosecution of their abuser goes forward. In these cases, it is important that health care workers provide ongoing support to patients who are involved as victims in criminal court cases. Nurse-midwives and other health care professionals can benefit their patients by meeting, getting to know, and interacting with prosecutors and victims' advocates in their community to learn how to support patients during trial. This requires a basic knowledge of the criminal justice system's approach to domestic violence and some knowledge about the difficulties that abuse victims can encounter as their cases move through the system. Many of the things that can occur in a criminal case may seem illogical to those who might expect that offering protection to victims from further abuse by their abusers would be a priority. Many court systems provide "victim witness advocates" to help victims in criminal court cases because the abuse victims can and do play an important role in the criminal prosecution. Model criminal court practice also recognizes that, in the large number of cases where the victims are willing to cooperate with a criminal prosecution, they need support through the criminal court process to be able to do so effectively without becoming disillusioned with the court system. Victim advocates stay in contact with the victim, notify her of court dates, take reports of additional contact with the abuser, supply those reports to prosecutors, and help the victim develop the strength to overcome her fears and testify in court in front of her abuser. Not all communities have victims' advocates available to assist in domestic-violence cases, or the advocates may have such high caseloads that they cannot offer the support a particular abuse victim needs. This is why the additional support provided by domestic-violence advocates from shelter programs and health care professionals can make the difference between the abused person dropping the case and continuing with it. Abuse victims can get frustrated with the criminal justice system for a number of reasons. The abuser who is arrested may only be held in jail for a few hours and released without notification to the abuse victim. Abusers who are arrested are frequently released on their own recognizance; in other words, batterers are released on

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the "honor system," without bail or bond. If an abuser will not be held in jail prior to the trial, the next best thing is to have the judge set a bond for his release and set conditions on his release that are similar to those contained in a CPO. A detailed "stay-away" order should be entered also when the abuser is released on his own recognizance. The abuser can be ordered by the court in the criminal case not to contact the victim, either directly by telephone or through a third party, not to stalk her, and to stay completely away from the victim and her children. Criminal stay-away orders can also order the abuser to comply with the terms of any protection order issued and to participate in a certified counseling program for batterers. The criminal stay-away order lasts only until the criminal cases has ended. For an abuser to be convicted of a domestic-violence crime, the prosecution must prove his guilt beyond a reasonable doubt. This heightened standard of proof means that it will be easier for an abuse victim to obtain a CPO than it will be for the state to obtain a criminal conviction. Health care providers who have observed an abuse victim's injuries can be vital witnesses in domestic-violence cases. Nurse-midwives should cooperate with prosecutors and be willing to testify in criminal cases about the abuse they treated and/or witnessed. When a batterer is convicted or pleads no contest in a criminal domestic-violence case, the court can impose punishment. Sentencing goals in criminal domestic-violence cases include stopping the violence; protecting the victim, her children and family, and the general community; reinforcing the criminal nature of the abuser's acts; and holding the abuser accountable (74). A recent positive trend in criminal domestic-violence prosecutions is to allow victims to make a statement to the court about the impact that the crime and the history of violence has had on their lives and the lives of their families. Victim impact statements are made immediately prior to sentencing of the perpetrator. They provide victims with an opportunity to inl]uence the court's sentencing decision and urge the court to issue orders that will offer victims ongoing protection and that will be appropriate to their needs. For instance, a victim may not be best served by incarceration of the perpetrator in a manner that will preclude him from working and supporting the victim and her children. The victim may wish to request that the court place the perpetrator in a work-release program and issue protection orders that will deter him from coming near the victim or the children during work hours. The nursemidwife can help the victim find appropriate counsel or advocacy services or can help her develop her statement and can accompany her to court, providing support as she presents her statement.

WORKING WITH ABUSE VICTIMS TO DEVELOP A SAFETY PLAN AND DEVELOPING CONNECTIONS WITH COMMUNITY RESOURCES Safety Planning

Health care professionals can provide the abused woman with referrals to resources in the community, so the battered woman can leave or create a safety plan. A resource list may include shelters, hotlines, economic resources, counseling, immigrants' rights groups, church programs that work with immigrants, and social and legal services. Before providing any patient with written materials, the health care provider should advise the patient not to take the material home with her where the abuser might find it. She should identify a safe location away from the abuser where she can store the information. The abuse victim must feel free to opt not to take referral information at any time because she is not ready for it or it is not safe to take it with her. Health professionals may wish to use a prescription pad to disguise the information so that she can safely take with her the number of a local shelter. A health care professional can assist a woman who wishes to leave her abuser immediately by helping her work out a plan that will help her leave safely. Women who have no plans to leave can benefit from the development of a safety plan that helps improve their safety in the abusive home and allows them to plan a safe escape route should they decide to leave at some time in the future. Safety plans for women who are remaining with their abusers can help abuse victims reduce the risk of injury and its severity and help protect their children from abuse. Safety planning includes identifying a friend or family member with whom she can stay temporarily when she needs to flee and can include information about temporary shelter and emergency hospitalization. The health care provider can counsel a patient not yet ready to leave the abuser to develop a safety plan (see Appendix C for a detailed sample safety plan developed by Ayuda, Inc.). Domestic-violence programs within a community will have extensive experience in safety planning. The provider should contact these programs to receive training on safety planning and to identify materials they use. Health care providers will not need to do safety planning with all battered women. Patients should generally be referred to domestic-violence experts who do safety planning on a regular basis. However, all health care providers need to understand the safety planning process so that they can explain safety planning to patients. In cases of abuse victims who are not willing to act on or take referrals, nurse-midwives and other health professionals may be the only professional in a position to do safety planning. Documenting the counseling and referral process in the patient's medical record provides

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important documentation for the patient who may later need this documentation in a court action against her abuser; it will also protect, prevent, and defend the health care provider against malpractice claims for failure to inform battered patients about their rights and to refer them to domestic-violence experts for assistance. The first step after educating the patient about domestic abuse is to work with the victim to help the victim visualize a life away from violence. The patient should be helped to plan ways out of the house. She will need to plan out and practice safe escape routes and think about the safest escape times. She should identify where she can go, whether she has friends or family with whom she can stay, and how those friends and family can help her, and she should investigate local shelter services. The victim should be advised to make copies of important papers (social security cards, passports, insurance cards, mortgage or rental documents, pay stubs, etc). Immigrant women should also take photographs from the relationship and other documentation about the validity of the marriage. Immigrant women are advised to consult an immigration lawyer before leaving the marital home and losing access to documentation that may be necessary for their immigration case. A battered woman doing safety planning needs to think about how she can take essential belongings and documents with her. She should prepare and store a small suitcase at a friend's home containing birth certificates, identification, copies of restraining orders, medications/prescriptions, phone numbers, clothes and comfort items, keys, bankbooks, checkbooks, credit cards, and the toys that are important to their children. Abuse victims also need to teach their children how to call 911 and need to help their children be safe during violent incidents. When a woman is in immediate danger, she should be urged to leave the violence and take her children with her; such steps will increase the likelihood that she will have success obtaining legal custody of their children. She should consider leaving temporarily and obtaining a protection order that removes the abuser from the family home. This approach prevents the abuse victim's displacement and improves her chances of successfully separating from her abuser. When the violence in their relationship requires that she live at an undisclosed location, she should instead be taken to a shelter or should go to the home of a friend or relative. She may need to be temporarily absent from work and should warn her supervisor and coworkers to take security precautions and instruct the receptionist that she will not accept calls from the batterer. She may need to change her telephone number. She can get emergency financial assistance from the county, local churches and community groups, or the Red Cross. Social service agencies can also help her coordinate services for herself and her children.

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CONCLUSION

As nurse-midwives begin to work with abuse victims, it is important to remember that all professionals encounter battered women who are at very different places on the abuse continuum. Some women may not be ready to try to leave their abusers; others will have tried to leave and failed; and still others will be ready to leave for the final time. Some women will choose to stay with their abusers and will seek legal system intervention to make the abuser change his behavior. All professionals must keep clearly in mind what they have learned about the dynamics of domestic violence and be careful not to view the health professional's efforts at intervention as a failure or the patient herself as a failure because they did not want to leave or did not succeed in leaving their abuser immediately. There are at least three different ways to succeed when working with battered women. The first approach involves patients who are ready to leave their abusers permanently. Domestic violence is identified by the nursemidwife, and the patient obtains a protection order that is enforced. The violence stops, and she continues to live with her children away from the batterer. Success can, secondly, be achieved when the woman is not ready to leave her abuser. In those cases, success is a reprieve from the violence. Women who stay with their abusers can still obtain protection orders to stop the abuse. These orders shift the balance of power in abusive relationships. The batterer ordered into counseling learns alternative methods of dealing with his anger and frustration. The protection order issued even though the parties will continue to live together can bring temporary or long-term relief from violence. A third form of success is harder to measure and appreciate. It is the most difficult for professionals who work with abuse victims with which to come to terms. In this case, the abused woman returns to her abuser without taking legal action, but has learned from a trusted professional that help is available and will be there when she needs it. She learns that domestic violence is a crime, that it is not her fault, and that she is not the only person suffering abuse. She obtains this information from a nonjudgmental professional who respects her and her decisions. She trusts the nurse-midwife and knows that when she needs help, she can ask for it. Those professionals who have worked with abuse victims for many years have learned that these interventions also can be successful. These cases feel like failures, even initially, because the victim retums to her abuser; however, if professionals do their jobs correctly, these victims do, over time, leave successfully. When they retum for help to leave, perhaps 3 or 7 years later, it may be due to the discussions the provider had with them and the information provided to them that served as the initial catalyst to them leaving.

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By b e i n g t h e r e for o n e ' s p a t i e n t s , h e a l t h c a r e p r o v i d e r s can help end the violence.

The author would like to express special thanks for assistance in preparing this article to Minty Siu Chung, who assisted in drafting the article, and to Catherine F. Klein, coauthor on a law review article summarizing the state of domestic violence laws nationally, which is cited throughout this article.

17. American Medical Association. Diagnostic and treatment guidelines on domestic violence, 14 9,11. 18. Derrick JH. Annotation: medical malpractice: liability for failure of physician to inform patient of alternative modes of diagnosis or treatment. 38 A.L.R. 4th 900, 1985. 19. Tarasoff v. Regents of the University of California, 551 P.2d 334 (Cal. 1976). 20. Lake PF. Revisiting tarasoff. Albany Law Rev 1994;58:97. 21. Gammon TE, Hulston J. The duty of mental health care proriders to restrain their patients or warn third parties. Mississippi Law Rev 1995;60:749-50.

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22. Division of Corrections v. Neakok, 721 P.2d 1121 (Alas. 1986).

1. Dobash RP, Dobash RE, Wilson M, Daly M. The myth of sexual symmetry in marital violence. Soc Probl 1992;39:74-5.

23. Women and violence. Hearing before the U.S. Senate Judiciary Committee. Senate Hearing 101-939. Washington, DC: United States Senate August 29 and December 11, 1990;2:140.

2. Dobash RP, Dobash RE, Wilson M, Daly M. The myth of sexual symmetry in marital violence,1 83. 3. Okun L. Termination or resumption of cohabitation in women battering relationships: a statistical study. In: Hotaling GT, et al, editors. Coping with family violence: research and policy perspectives, 1988:107, 113. 4. Holtz H, Furniss K. The health care providers role in domestic violence. Trends Health Care Law Ethics Spring 1993;8:47, 50. 5. Warshaw C. Identification, assessment and intervention with victims of domestic violence. In: Lee D, Duborow N, Salberg PR, Heisler C, Letellier P, Hart B, editors. Improving the health care response to domestic violence: a resource manual for health care providers. San Francisco: Family Violence Prevention Fund, 1995:78-9. (A manual for health care providers on domestic violence produced by the federally funded National Resource Center on Health and Domestic Violence.) 6. Orloff L. Potential for health professional legal liability for actions or inactions in domestic violence cases. Legal memorandum for the State of Alaska, Department of Health and Social Services, Division of Public Health, Section of Maternal and Child Health for its Train the Trainers Workshop, 1996. 7. Warshaw C. Identification, assessment and intervention with victims of domestic Violence, ~ 78. 8. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law. Hofstra Law Rev Summer 1993;21:809, 1112. 9. National Coalition Against Domestic Violence. National estimates and facts about domestic violence. NCADV Voice: Special Edition: Battered Women In Prison 1989:12. Washington (DC): NCADV. 10. Dutton MA, Dionne D. Counseling and shelter services for battered women. In: Steinman M, editor. Woman battering: policy responses. Cincinnati: Anderson, 1991:121. 1 i. Zelen JE. Annotation: physician liability for unauthorized disclosure of confidential information about patient. 48 ALR 4th 668, 1986. 12. Hyman A, Chez R. Mandatory reporting of domestic violence by health care providers: a misguided approach. In: Lee D, Duborow N, Salberg PR, Heisler C, LeteUier P, Hart B, editors. Improving the health care response to domestic violence: a resource manual for health care providers. San Francisco: Family Violence Prevention Fund, 1995. 13. Pike CL. Note: the use of medical protocol in identifying battered women. Wayne State Law Rev 1992;38:1941-3. 14. American Medical Association. Diagnostic and treatment guidelines on domestic violence. Chicago: American Medical Association, 1992. 15. American College of Obstetricians and Gynecologists. Educational bulletin: domestic violence. Washington, DC: American College of Obstetricians and Gynecologists, 1996. 16. Bell D. The police response to domestic violence: a multi-year study. Police Stud 1985;8:58.

24. National Council of Juvenile and Family Court Judges, Family Violence Project. Family violence: improving court practice, recommendations from the National Council of Juvenile and Family Court Judges. Reno, Nevada: National Council of Juvenile and Family Court Judges, 1990:22. 25. Browne A. Violence against women by male partners: prevalence, outcomes, and policy implications. Am Psychol 1993;48:1077,1080-1,1084. 26. Ganley AL. Domestic violence: the what, why and who, as relevant to civil court cases. In: Carter J, Heisler C, Isaacs R, Jang D, editors. Domestic violence in civil court cases: a national model for judicial education. San Francisco: Family Violence Prevention Fund, 1992:20. 27. Follingstad DR, Rutledge L, Berg B, Hause E, Polek D. The role of emotional abuse in physically abusive relationships. J Fam Violence 1990;5:113-4. 28. Ganley AL. Domestic violence: the what, why and who, as relevant to civil court cases, 26;23. 29. Orloff L, Ayuda. Power and control tactics used against immigrant women. Washington, DC: Ayuda, 1996: i - 3 . 30. Browne A. Violence in marriage. In: Ohlin L, Tony MH, editors. Family violence. Chicago: University of Chicago Press, 1987:7. 31. Rafael J. Future questions in policy research and practice: the relationship between domestic violence and welfare reform. Chicago: The Taylor Institute, 1995. 32. Browne A. Violence against women by male partners: prevalence, outcomes, and policy implications. Am Psychol 1993;48:1077,1080-1,1084. 33. Hogeman C, Rosen K. Dreams lost, dreams found: undocumented women in the land of opportunity. San Francisco: Coalition For Immigrant and Refugee Rights and Services, Spring 1990:49,63. 34. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law, ~ 1019-22. 35. United States Commission on Civil Rights. Racial and ethnic tensions in American communities: poverty, inequality and discrimination. Washington, DC: U.S. Government Printing Office, 1993:75. 36. Ganley AL. Understanding domestic violence. In: Warsaw C, Ganley A. Improving the health care response to domestic violence: a resource manual for health care providers. San Francisco: Family Violence Prevention Fund, 1995:34. 37. Kurz D. Social science perspectives on wife abuse: current debates and future directions. Gender Soc 1989;3:493. 38. Volpp L. Working with battered immigrant women: a handbook to make services accessible. San Francisco: Family Violence Prevention Fund, 1995:13. 39. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law, 8 848-66,874-6, 1142-58.

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40. Sheridan DJ. The role of the battered woman specialist. J Psychosoc Nurs 1993;31(11):31. 41. Orloff L. Social issues and family violence--respecting culture in work with battered immigrant women. In: American Medical Association. National Conference on Family Violence: Justice and Health Conference Proceedings. Chicago: American Medical Association, 1994:69. 42. Committee on the Judiciary. Report on the Violence Against Women Act To Accompany H.R. 1133, H.R. Report No. 395, 103rd Congress, 1st session 1993:26-7. 43. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 1022-5. 44. Goldberg W, Tomlanovich MC. Violence, victims and emergency departments: new findings. JAMA 1984;251-9. 45. American College of Obstetricians and Gynecologists. Unpublished data, 1993. 46. Warshaw C. Identification, assessment and intervention with victims of domestic violence,s 61. 47. Rodriguez R. Final report: suffering in silence. Austin, Texas: Migrant CliniciansNetwork, 1995. 48. Task Force on Racialand Ethnic Bias and Task Force on Gender Bias in the Courts, District of Columbia Courts, Final Report. May 1992; Appendix H:20. 49. Warshaw C. Identification, assessment and intervention with victims of domestic violence,s 72. 50. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 809. 51. Finn P, Colson S. Civil protection orders: legislation, current court practice and enforcement. Washington, DC: National Institute of Justice, 1990:1. 52. Orloff L, Ayuda. Legal options for battered women. Washington, DC: Ayuda, 1996. 53. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 814. 54. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 816. 55. Harlow C. Female victims of violent crime. Washington, DC: United States Department of Justice, 1991:1. 56. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 820.

57. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 821. 58. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 837. 59. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 829-35. 60. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 832. 61. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 824. 62. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 1074-8. 63. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 849-54, 858. 64. Newbouse HR, Goldfarb S. NOW Legal Defense Fund Testimony--Women and violence: hearings of legislation to reduce the growing problems of violent crime against women before the Senate Committee on the Judiciary, 101st Congress. 2nd Session, 72 (1990). 65. Bureau of Justice Statistics. Highlights from 20 years of surveying crime victims. Washington, DC: United States Department of Justice, 1993:25. 66. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 854-8. 67. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,~ 859-64. 68. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 866-9. 69. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 821. 70. Bureau of Justice Statistics, U.S. Department of Justice, Special Report: Preventing domestic violence against women. Washington (DC): U.S. Dept. of Justice, 1986 Aug. 71. U.S.v. Dixon, 113 S. Ct. 2849 (1993). 72. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 1142-4. 73. Klein CF, Orloff LE. Providing legal protection for battered women: an analysis of state statutes and case law,8 1148-55. 74. Orloff L. Social Issues and family violence--respecting culture in work with battered immigrant women,41 72.

APPENDIX A Types of Relief Typically Available Through a Civil Protection Order 1. Refrain from further abuse to the victim, her children, or her household m e m b e r s . 2. Stay away, have n o contact with the victim, her children, her family members, or her household members. 3. Stay away from the victim's h o m e , p e r s o n , workplace, school, church, a n d her children's school. 4. H a v e n o c o n t a c t or c o m m u n i c a t i o n in p e r s o n , by t e l e p h o n e , by letter, or t h r o u g h third parties with the petitioner. 5. O r d e r the abuser to leave (vacate) the family h o m e , n o t to r e e n t e r the h o m e , s u r r e n d e r his keys, a n d n o t d a m a g e the premises, discontinue mail service, or shut off utilities. 6. Award the petitioner use of p e r s o n a l property, including the car.

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7. O r d e r the police to r e m o v e the a b u s e r from the vict i m ' s h o m e a n d a c c o m p a n y the victim w h e n p r o p erty is e x c h a n g e d . 8. O r d e r the abuser to s u r r e n d e r w e a p o n s (69). W h e n the victim is a w a r e that the abuser o w n s w e a p o n s , her p r o t e c t i o n order request c a n include a request that the police confiscate the a b u s e r ' s w e a p o n s . M a n y states order this relief u n d e r the "catch all" provision of their statute. U n d e r the Violence A g a i n s t W o m e n Act, p e r s o n s w h o have p r o t e c t i o n orders issued against t h e m are n o t legally entitled to o w n firearms as a m a t t e r of federal law. 9. Award custody to the n o n a b u s i v e p a r e n t a n d order that a p r e g n a n t w o m a n be a w a r d e d t e m p o r a r y custody should a child be b o r n from the p r e g n a n c y . This avoids conflict over custody of the child at the hospital or while the m o t h e r is r e c u p e r a t i n g from childbirth.

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10. Order visitation to the abuser under conditions that protect the safety of the victim and the children (these provisions usually are designed so that there is no contact between the parties with respect to visitation and can include supervised visitation). 11. Order monetary relief to the victim, including payment of medical bills, spousal support, child support, and other forms of monetary relief. 12. Order the abuser into a batterer's treatment program, substance abuse program, or psychiatric counseling. Abusers should only be ordered into treatment with programs and mental health professionals who have experience working with batterers. Counseling programs must 1) assess the respondent's suitability for domestic-violence treatment, including his propensities for dangerousness, his motivation to change, and the safety needs of

the victim, her children and other family members, 2) holds the abuser accountable for his violence, 3) does not place any responsibility for the abuser's violence on the victim, 4) ensure that the victim's safety is addressed, and 5) be accountable to the courts and the police. Long-term counseling of not less than 1 year is recommended, because shortterm counseling is generally ineffective. 13. Order the police to serve protection orders and notices of protection order hearings on abusers. 14. Order the police to notify the victims orally and in writing of their rights and the services available in the community to assist abuse victims. In some jurisdictions, reasonable effort must be taken to give notice to the abuse victim in her own language. 15. Order any other relief that will help stop the violence in the relationship.

APPENDIX B Relief Typically Available as Part of a Temporary Protection Order

I. 2. 3. 4.

A stay-away and no-contact order. No-abuse provisions. Temporary custody of minor children. Cessation of visitation until a court hearing can be held.

5. An order requiring the abuser to vacate the family home.

6. An order requiring the police to serve the temporary protection order on the abuser and requiring them to obtain his keys and stay at the home he shares with the victim while he removes his personal effects and sufficient clothing to last until the court hearing date.

APPENDIX C Safety Plan*

1. Create a safety exit from your place of residence. Practice a safety escape plan with your children. What doors, windows, elevators, stairwells, or fire escapes would you use? 2. Plan the safest time to get away. 3. Tell someone what is happening to you. If possible, inform your neighbors of your situation and tell neighbors to call the police if they hear any suspicious noises coming from your home. You could also arrange a signal with neighbors to let them know you are in danger, ie, flashing lights, and have them call the police when they are signaled. You might also have a code word with your children or your friends so they can call for help. *Reprinted with permission from Ayuda Inc. Assisting Battered Immigrant Women and Children Filing Immigration Claims Under the Violence Against Women Act: A Manual for Immigration Attorneys, Domestic Violence Advocates, and Family Lawyers. Washington (DC): Ayuda Inc., 1995.

. Know where you can go for help. Check with close friends and/or relatives if you could stay with them in an emergency situation until you could find a more permanent residence or return home. Keep the following objects at their home: - - a spare set of keys - - a set of clothes for you and your children - - a copy of important papers, including any protection orders, custody orders, and immigration documents --prescriptions - - s o m e money --social security cards --children's school and immunization records - - p h o n e numbers of friends, relatives, and domestic-violence programs - - a n y other important materials for you and your children's daily activities If it will be impossible for you to move in with a friend or relative, find out where you can call when you flee to obtain emergency refuge at a shelter.

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5. In an emergency escape from your batterer, you must take your children with you if it is at all possible. Check with the friend or relative you plan to stay with in an emergency situation if you can bring your children with you. If you plan to stay in a shelter, be advised that many shelters do not accept children. Even though it may seem more sensible to leave school-age children at home if you do not know to where you are escaping or for what length of time, failing to take the children with you could make it more difficult to regain custody of your children should you decide not to return. The overwhelming majority of battered women who flee with their children receive legal custody of their children from the courts. Further, if you leave your children with your partner, you will also leave your partner with a very effective tool that he can use to control your life--your children. 6. Teach your children to dial 911 in an emergency. 7. Plan with your children and identify a safe place for them if another domestic violence incident should occur--a room with a lock or going to a neighbor's house where they can go for help. Reassure them that their job is to stay safe, not to protect you. 8. Have an easily accessible place to keep your car keys, purse, and any other essential items should you have to leave in a hurry. 9. Take photographs of any injuries you sustain. Also, take photographs of torn clothing, broken property, and furniture in disarray. Take these photographs when it is safe to do so and leave copies of the photographs and the negatives outside your home in a safe place. 10. Keep any evidence of physical abuse (ripped clothes, photos of bruises, etc). Should you ever decide to take legal action against your abuser, you will need these items. Remember to keep this evidence and photographs in a safe place away from your abuser.

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11. Open a savings account to increase your independence and to have access to some money that may need if you leave your abuser. 12. Keep change for phone calls with you at all times. If you are still living with your abuser and you call for help or information related to the abuse from home, be sure to call another number that he would not question (ie, to church or sister or mother) immediately after that call so that he cannot use the redial feature of the telephone to discover what number had been dialed. Do not use your telephone calling card, because the first month after you leave, the abuser will have access to your phone bill listing the numbers you have called. 13. Learn about the cycle of violence and learn to recognize when a violent episode may occur. Leave the house before the attack takes place. 14. If you foresee an outbreak of violence, move away from weapons to a lower-risk place near an exit. Avoid bathrooms, the kitchen, or the garage. 15. Use your judgment and intuition. If the situation is very serious, you can give your partner what he wants to calm down. You have to protect yourself until you and your children are out of danger. 16. Try not to use weapons to defend yourself. When the police arrive, you may not be able to convince them you are defending yourself. Your best approach is to escape the violence, to call the police, or have someone call the police for you. 17. If you are injured, go to a hospital emergency room and report what happened to you. Ask that they document your visit. If your abuser insists on taking you to the hospital, ask that you be interviewed in private, if it is safe to do so. 18. Contact the local domestic-violence hotline to find out about laws, shelters, and other resources available to your before there is a crisis and you have to use them.

Journal of Nurse-Midwifery • Vol. 41, No. 6, November/December 1996