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Intimate Partner Violence: A Review for Nurses
CNE Intimate Partner Violence A Review for Nurses
Carol L. Krieger, APRN, MSN, BC
Objectives Upon completion of this activity, the learner will be able to:
1. Differentiate between the different types of intimate partner violence (IPV). 2. Cite statistics and trends regarding IPV, including prevalence rates, differences among different racial and ethnic groups, and economic implications. 3. Identify universal IPV screening and assessments pertinent for victims of IPV. 4. Describe education and safety information nurses can provide to victims of IPV.
Intimate partner violence (IPV), also called domestic violence (DV), is a health care problem that physically and mentally traumatizes women, men and children, and leads to chronic health problems for the victims. Victims of IPV may undergo unnecessary diagnostic testing for chronic physical symptoms that may be due to physical and emotional abuse (Mahoney, 2006). The physical abuse may be treated by the health care professional; however, the nurse must also address the underlying causes of these injuries and provide the victim with safety education. The Centers for Disease Control and Prevention (CDC, 2003) state that IPV is a serious preventable public health problem affecting more than 32 million Americans or more than 10 percent of the U.S. population (Tjaden & Thoennes, 2000a). IPV doesn’t always leave the victim with visible scars. The perpetrator may abuse the victim with a smile upon their face and the perpetrator may feel that they are entitled to abuse others. The scars are felt much deeper in the victim’s heart and soul.
Continuing Nursing Education (CNE) Credit
STATISTICS
A total of 2 contact hours may be earned as CNE credit for reading “Intimate Partner Violence: A Review for Nurses” and for completing an online post-test and participant feedback form.
Statistics about IPV are difficult to determine because it’s estimated that only 20 percent to 50 percent of the assaults are reported to the police (The National Domestic Violence Hotline, 2008). Tjaden and Thoennes (2002a) estimate that only 25 percent of all physical assaults against women, and fewer assaults against men, are reported to the police. Coker et al. (2002) estimate that 29 percent of all women and 22 percent of all men will experience physical, sexual or psychological abuse in their lifetime. Many experts believe the true magnitude of the abuse is greatly underestimated. According to the CDC (2006), each year women experience about 4.8 million intimate partner–related physical assaults and rapes, and men are the victims of about 2.9 million intimate partner–related physical assaults. IPV resulted in 1,544 deaths in 2004 (CDC, 2006). Of these deaths, 25 percent were males and 75 percent were females. These statistics translate into economic effects, as well. The CDC (2003) estimated that in 2003, the economic costs of IPV exceeded $8.3 billion. Persons affected by IPV have a productivity loss of 8 million days of paid work (the equivalent of 32,000 full-time jobs) and 5.6 million days of unpaid household work each year (CDC, 2003). Abusers may not allow victims to work or attend college. Women who experience IPV are more likely to be unemployed, have health problems and receive public assistance than are women who are not victims of IPV. Additional work may be required of coworkers due to victims’ absenteeism. Tax dollars are used to support programs to assist victims.
To take the test and complete the participant feedback form, please visit http://JournalsCNE. awhonn.org. Certificates of completion will be issued on receipt of the completed participant feedback form, application and processing fees. AWHONN is accredited as a provider of continuing nursing education by the American Credentialing Center’s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama # ABNP0058.
Carol L. Krieger, APRN, MSN, BC, is a visiting assistant professor at the University of Toledo, a psychiatric nurse practitioner at Harbor Behavioral Healthcare, and coordinator of the Domestic Violence and Sexual Assault Nurse Examinator in the Emergency Department at the University of Toledo Medical Center, Toledo, OH. The author reports no conflicts of interest or financial relationships relevant to this article. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2008.00327.x Opening photo © Fotolia VI / Fotolia.com
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DEFINITIONS IPV or DV may be defined as any behavior that causes physical, mental, sexual, emotional or social isolation or abuse to the victim, who is in an intimate relationship with the abuser (Family Violence Prevention Fund, 2008). Domestic violence is considered an older term, whereas intimate partner violence
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IMPACT ON INDIVIDUALS, FAMILIES AND SOCIETY IPV affects females and males of all ages and racial, educational, cultural and economic backgrounds. The groups found to have the highest prevalence of IPV are American Indian and Alaskan Native women and men, black women and Hispanic women (Tjaden & Thoennes, 2000b). IPV includes violence within same-sex relationships and among family members. The majority of abuse victims are women (Rennison, 2003). Johnson and Leone (2005) state that victims of repeated violence over time
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Children who live in a household in which IPV occurs are at greater risk of the following: • Psychiatric disorders • Developmental problems • School failure • Violence against others • Low self-esteem
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BOX 1 RISKS FOR CHILDREN
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experience more serious injuries than do is considered a more modern term e victims of one-time abuse incidents. Young that recognizes that intimate partv e c iolen partner v te a women and people closer to the poverty ners don’t always live within the w m c ti sti • In lled dome a c o ls a line are affected more often than any same household. The terms are used li ), (IPV mpasses o c n e , e c n other population (Heise & Garcia-Moreno, interchangeably in this article. o viole exual, mental, s buse. 2002). Children who live in a household in A comparison of the definition 2 physical, a economic which their mothers are being abused are of the term “intimate partner” was w social and ’t often don V IP f o 57 times more likely to be harmed (Parkincompleted in a Midwestern state, an 5 s • Victim . e s u b a e Eastern state and Western state. All sson, Adams, & Emerling, 2001) (see Box 1). report th for IPV n e re Perpetrators of IPV cause instability three states defined an intimate partP c s n a c t • Nurses tims abou ic v l e within their families while causing physical ner as a current or former spouse or w s n u o and can c . s e rc u o s and psychological damage. a current or former cohabitant, and a re safety and IPV can be difficult to identify bealso included dating and engagement relationships. Additionally, ccause it often occurs in private and bein all three states “intimates” were ccause victims are often reluctant to report also defined as parents of children iincidents to anyone because of shame together and those persons related aand fear of reprisal by family members and friends. Victims who stay with their by consanguinity or affinity, which abuser are often ostracized by family members and friends who literally means “blood relationship.” The East Coast state indon’t understand the psychological attachment between the cluded in the definition those persons in relationships who may victim and the abuser. be sexually consummated or not, as well as in gay, lesbian, biThe U.S. Department of Justice (2007) reports that female sexual and transgendered relationships. victims are substantially more likely than male victims to be In IPV, there exists an abusive relationship in which the perkilled by an intimate partner. Male abusers kill their female petrator desires to have power and control over the victim; IPV partners four times more often than female abusers kill males is not about anger but rather the desire to instill fear in the vicinvolved in IPV. Between 1976 and 2004, a higher number tim. The perpetrator gradually creates fear in the victim in which of homicides involved spouses; however, in recent years the there is a slow disintegration of a victim’s sense of self and selfnumber of deaths by boyfriends and girlfriends have increased image. This process increases the victim’s feelings of devaluing (Rennison, 2003). The intimate homicide rate between 1976 and isolation. Victims are more likely to accept this abuse if they and 2004 fell by 82 percent for black males and by 56 percent were exposed to verbal, physical or sexual victimization in their for black females, across all relationship categories (Rennison, childhood (CDC, 2006). Secrecy is an abuser’s best protection. 2003). The rate declined by 55 percent for white males and only A victim of IPV may display low self-esteem, depression, an5 percent for white females (U.S. Department of Justice). More tisocial behavior, inability to trust, fear of intimacy and suicidal than two-thirds of spouse and ex-spouses victims of IPV were behaviors due to anxiety related to the abuse and fear of the killed by guns between 1976 and 2004. Female abusers were discovery of the abuse (Bergen, 1996; Coker et al., 2002; Heise more likely to kill their boyfriends with knives than were any & Garcia-Moreno, 2002; Roberts, Klein, & Fisher, 2003). Older other group of intimates. Large gaps remain in IPV research women are more likely to experience violence for a longer time related to culture and ethnicity and these areas require further and to remain in a violent relationship than are younger women, exploration. because older women may feel they have fewer opportunities because of their age. Women who have been in a long-term abusive relationship have a higher incidence of chronic health and mental health problems (Johnson & Leone, 2005).
PHYSICAL ABUSE Physical abuse includes the abuser spitting, kicking, punching, grabbing, slapping or strangulating the victim. Women with a history of IPV report 60 percent higher rates of all health problems than do women with no history of abuse (Campbell et al., 2003). The IPV victim may arrive in the doctor’s office or emergency room with vague, chronic, non-specific complaints and a history of overuse of health services or unexplainable injuries such as bruises or fractures. Advanced practice nurses should consider their patients’ chronic complaints as possible abuse symptoms. Women may undergo unneeded diagnostic testing to try to elucidate the cause of these chronic conditions (Mahoney, 2006). See Box 2 for signs of IPV. The abuser may insist on staying with the victim during the health care examination and refuse to leave the victim’s side. The abuser may appear to act overly attentive toward the victim to discourage the victim’s disclosure of the abuse to the health care provider. The abuser may insist on informing the care provider how the victim was injured and may not allow the victim to talk to the care provider in private; the information of how the victim was injured may not match the victim’s injuries. Victims may have repeated accidental injuries and delay receiving treatment for serious injuries. Crandall, Nathens, Kernic, Holt, and Rivara (2004) found that 93 percent of female IPV victims had at least one previous injury visit to a health care facility, and 44 percent of women murdered during IPV had visited an emergency department within two years of being murdered. Another form of physical abuse is strangulation. Strangulation is a form of asphyxia or lack of oxygen caused by a forced pressure injury to the victim’s neck. This injury may be caused by the hand (manual) or by a ligature, such as a rope or clothing. Ten percent of the violent deaths in the United States are due to strangulation, with six females being killed for every one male (Strack & McClane, 1999). The patterns of injury, such as bruising or ligature marks, may allow the care provider to determine if the blunt force trauma was caused by strangulation, hanging or traumatic blows to the neck. Hawley (n.d.) states the immediate death from strangulation is usually caused by the pressure on the carotid arteries, which prevents blood flow to the brain or pressure on the jugular veins, which prevents blood flow from the brain. Strack and McClane state that an 11-pound pressure placed on both carotid arteries for 10 seconds will cause the victim to become unconscious. If this pressure is released, the victim will gain consciousness in 10 seconds. Strack and McClane (1999) found that victims who were strangled may have physical evidence of an injury to the neck in only 50 percent of strangulation cases and in only 35 percent of minor cases. Visible evidence such as red marks, bruises or rope burns may be found in only 15 percent of strangulation cases (Strack & McClane). Only three percent of victims who were strangled sought medical care (Strack & McClane). These victims usually sought care only due to a complaint of
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persistent throat pain, voice changes or trouble swallowing. Strangulations that do not result in immediate death must be investigated by the care provider carefully due to possible hyoid fracture, which results in approximately one-third of all fatal strangulations (Hawley, n.d.). The hyoid bone is a small horseshoe-shaped bone in the neck that supports the tongue. Because this injury does not always provide evidence, the victim may not be admitted for observation and may be discharged to their home. Breathing changes may initially be mild; however, underlying injuries such as injuries to the hyoid bone or underlying structures may kill the victim up to 36 hours later due to asphyxiation (Strack & McClane).
MENTAL OR EMOTIONAL ABUSE Mental or emotional abuse such as coercion, threats and stalking may also be inflicted on abuse victims by perpetrators. According to Tjaden and Thoennes (2000a), more than 1 million women and 371,000 men are stalked by intimate partners. The perpetrator may verbally abuse the victim with put-downs, insults, criticism or name-calling. The perpetrator may intimidate the victim by giving the victim certain looks or gestures to instill fear. The perpetrator may coerce the victim by threatening to harm children, family members and pets. Abusers often destroy the victim’s property, abuse their pets or display weapons to force the victim into submitting to the perpetrator’s wishes. The abuser may convince children to view the victim as having caused the abuse by causing the perpetrator to become angry; thus, the children may blame the victim. Abusers commonly play the “blame game” with those they abuse. The abuser may blame the victim for being clumsy and may deny harming the victim. The abuser may minimize the victim’s injuries and provide excuses for the abusive behavior. The abuser may attempt to convince others that the victim is incompetent or crazy and is not to be believed or taken seriously.
SEXUAL ABUSE Sexual abuse may include the perpetrator forcing sexual intercourse or sexual activities against the victim’s will. Rapes and
BOX 2 SIGNS OF IPV • Overuse of health services • Vague, non-specific complaints • Missed appointments • Unexplainable injuries • Untreated serious injuries • Injuries not matching the description • Intimate partner never leaving the patient’s side • Intimate partner insisting on telling the story of the injury
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Social abuse may include isolating or limiting the victim’s contacts with family and friends and requiring the victim to obtain permission to leave the house. The abuser may not allow the victim to attend work or school and may control the victim’s social activities; an abuser might also check the odometer of the victim’s car as a way to “keep tabs” on the victim and might also require the victim to provide a detailed account of any time spent away from the abuser. The perpetrator may restrain the victim’s access to medical services or cause the victim to miss medical appointments, which causes strained relationships with health care providers, employers, friends and family members (Heise & Garcia-Moreno, 2002; Plichta, 2004). The perpetrator may damage the victim’s reputation and intimidate the victim’s
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IPV is a serious preventable public health problem affecting more than 32 million Americans or more than 10 percent of the U.S. population. 371,000 men are stalked by IPV abusers. Tjaden and Thoennes (2000b) estimate that only 50 percent of stalking activity against women is reported to the police. The Center for Policy Research (1997) states that 80 percent of women who are stalked by former husbands are physically assaulted and 30 percent are sexually assaulted. Stalking must be taken as a serious threat and the victim should be encouraged to report this abuse to the police.
ECONOMIC ABUSE Economic abuse may include the perpetrator controlling the victim’s finances, refusing to share money, making the victim account for money spent and not allowing the victim to work outside the home. The abuser desires that the victim be emotionally and financially dependent on the abuser. The abuser may also try to sabotage the victim’s work performance by forcing her to miss work or by calling the victim frequently at work and causing her to lose her job. The American Bar Association (2008) reports that 70 percent of IPV victims are employed and more than 70 percent of them report that their abusers harass them at work either over the telephone or in person. The American Bar Association reports that perpetrators cause more than 60 percent of their victims to be either late to and/or absent from work.
PHASES OF ABUSE The IPV abuser exhibits three phases of abuse (Varcarolis, Carson, & Shoemaker, 2006). Phase one includes a tensionbuilding phase that may include the abuser calling the victim inappropriate names and pushing or shoving the victim. During the first phase, the victim attempts to deny that the abuse will happen and tries to please the abuser to prevent abuse; however, this often only postpones rather than prevents the abuse.
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SOCIAL ABUSE
family and friends. The perpetrator causes a breakdown in the victim’s relationships that could provide emotional support for the victim. McFarlane, Parker, and Soeken (1996) found that 50 percent of men who frequently assault their wives also assault their children. Nelson, Nygren, McInerney, and Klein (2004) report that children who witness IPV are at a greater risk of developing psychiatric disorders, developmental problems, school failure, violence against others and low self-esteem. Social abuse may also include the abuser stalking the victim. The CDC (2003) has reported that one million women and
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sexual assaults committed by strangers are more likely to be reported than are rapes and sexual assaults committed by an intimate partner (Rennison, 2003). In one study conducted between 1992 and 2000, 41 percent of rapes and sexual assaults committed by strangers were reported, whereas only 24 percent of rapes and sexual assaults committed by an intimate partner were reported (Rennison, 2003). Sexual abuse may include the victim being forced to participate in early sexual initiation, decreased condom use or unprotected sexual intercourse, having multiple sexual partners, and trading sex for food, money or other items (CDC, 2003). This sexual activity may increase the victim’s chances of being exposed to sexually transmitted infections, including human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). Sexual abuse can also include forcing an undesired pregnancy or forcing pregnancies to occur rapidly one after another. Pregnancy is a particularly dangerous time for any abused woman. Not only is the woman’s health and life at risk, but also the health and life of the fetus. IPV may begin or increase with pregnancy because the abuser may feel trapped in the relationship and feel the added pressure to provide emotional and financial support for the mother and child. A study completed by Gazmararian et al. (2000) found that 324,000 pregnant women are abused by their partner at least once during their pregnancy each year. The Family Violence Prevention Fund states that IPV accounts for 31 percent of the homicides among pregnant women and is the leading cause of traumatic death for pregnant and postpartum women in the United States. Tjaden and Thoennes (2000a) estimate that among women between the ages of 20 and 44, only 20 percent of IPV rapes and sexual assaults are reported to the police. The CDC (2006) report that 1.5 million women and 800,000 men are raped or physically assaulted each year. The CDC further clarifies these numbers as 47 IPV assaults per 1,000 women and 32 assaults per 1,000 men. Tjaden & Thoennes (2000a) have reported that Hispanic women are more likely than non-Hispanic women to report intimate partner rape.
The second phase is the act of the abuser inflicting violence on the victim (Varcarolis, Carson, & Shoemaker, 2006). In this phase, abusers make victims feel that they’ve angered the abuser, making victims feel responsible for the abuse. Victims often feel that if they were “smarter,” then the abuse would not have happened. The third phase is often referred to as the “honeymoon” (Varcarolis, Carson, & Shoemaker, 2006), in which the abuser is overly apologetic and expresses guilt and shame for the abuse. Abusers often promise victims that they won’t harm them or their family or pets again. The abuser may beg the victim for forgiveness using the victim’s religious or cultural beliefs to encourage the victim to forgive the abuser. The victim may believe the abuser’s words and intent to change and return to the abuser due to religious and cultural convictions. The abuser may also offer the victim gifts or a promise to stop abusing. Abusers may threaten to commit suicide or kill others if victims don’t return to them. Once abusers have apologized to victims, they begin to blame the victim, saying that the abuse wouldn’t have happened if the victim hadn’t “said or done something” to make the abuser angry. Women who have separated from a violent partner often remain at risk (Campbell et al., 2003; Fleury, Sullivan, & Bybee, 2000).
UNDERSTANDING VICTIMS’ ACTIONS Kearney (2001) completed research in women between the ages of 16 and 67 on the rationalizations of why victims remain and even return to their abusers, and detected four phases of recovery for the victim. The first phase includes a theme of feeling an “enduring love” and obligation to the relationship. The victim
Women who have separated from a violent partner often remain at risk. enters into a relationship to fulfill the desire of loving and being loved and believes this relationship to be forever. Many victims may have religious values or live in a culture that doesn’t advocate separation and divorce, and may fear the mental anguish of being separated from their family and friends. Family members and friends may not believe that the victim has been abused or may minimize the abuse and be unwilling to assist the victim in separating from the abuser. The victim may have fear of the disclosure of the abuse and minimize the abuse. Victims may feel guilt and shame and blame themselves for the abuse and may feel the need to protect abusers to maintain their love and devotion. The second phase, according to Kearney (2001), includes the theme of “the more I do, the worse that I am,” which describes the victim as trying to meet the abuser’s needs in every way possible, despite how unpredictable the abuser’s behaviors are. Abuse becomes a regular part of the relationship and the victim can no longer pacify the abuser to avoid the abuse.
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Victims begin to doubt themselves and lose their identity. Victims restrain their emotions and reactions to avoid abuse. Victims often display harmful behaviors such as substance abuse, alcoholism and suicide attempts to cope with the emotional strain of the abuse (CDC, 2003). They may also use coping behaviors, such as practicing detrimental dieting behaviors such as fasting, vomiting, abusing diet pills and overeating to regain a small amount of control over their lives (CDC, 2003). The third phase of the violent relationship as defined by Kearney (2001) includes a theme of “I’ve had enough” (2001). This is the stage when the victim has determined that the relationship is abusive and has decided not to continue to tolerate the abuse. An episode such as harming the children may incite the victim to take action to leave the abuser. The victim may have fear of the unknown and of being alone and may lack knowledge regarding what to do and where to go for safety. This is an opportune time for the nurse to provide information and education for the victim to leave the abuser if they are receiving treatment. Nurses should learn about services in their area that may assist the victim and provide safety information. Nurses should advocate posting literature about abuse in the community and providing victims with telephone help numbers and other resources. Many IPV agencies provide cards with telephone numbers in public restrooms, as the restroom may be the only area that the perpetrator may allow the victim to be by themselves. During this phase, the victim is aware and open to starting a new life without the abuser. Valente (2002) has documented that most women will not stay in abusive relationships and will leave within the first two years; however, the women may make several attempts of leaving the relationship until the final separation is completed. Wives who leave their husbands had a two to four times greater risk of being killed by their spouse after a separation (Valente). The fourth and final phase of the violent relationship is defined by Kearney (2001) as “I was finding me.” In this phase, the victim has established a life separate from the abuser. The victim may deplete resources while being separated from the abuser and may begin to question her decision of leaving the abuser. Victims may have little experience with economic independence and may think that they don’t have the skills to support themselves and their children. This is a time when women need support and encouragement to remain separate from the abuser. The victim is in a time of self discovery and recovery and is going from a “being a victim to becoming survivor.”
IMPLICATIONS FOR NURSING PRACTICE Screening for IPV should become a routine part of health care assessment in all females over the age of 14, regardless of the presenting problem (Roberts & Petretic-Jackson, 1998). The initial screening should include general questions and should be conducted on a one-to-one basis within the health care setting (Valente, 2002). If the screening tool suggests that the
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BOX 3 SAFETY STRATEGIES Victims of IPV should try to maintain the following safety strategies: • Always be aware of surroundings • Minimize time in kitchens, bathrooms and closets when abuser is near • Shop and bank at different places • Drive to work multiple ways • Get a protection order • Never lunch alone • Cancel joint credit cards and old bank accounts with abuser • Provide a picture of abuser to security at workplace • Be escorted by workplace security to car or transportation • When in danger, go to a place of safety and call 911 • Change locks on house if abuser has moved out • Get unlisted telephone number • Block caller ID The victim may consider using a friend’s computer or a computer at the library for safety to avoid the abuser having access to the email addresses of the victim’s family members and friends. The victim should be encouraged to change online passwords and create a new email account to avoid the abuser’s harassment. Many agencies encourage the victim to pack a bag with important items that will be needed if she must escape from the abuser quickly. This bag may be placed in a safe place or given to a friend or relative for the safe keeping. This bag may include extra car keys, medications, credit cards, court papers, passports, birth certificates, medical records and immigration papers or copies of these documents (see Box 4). The victim will need these documents to establish stability, such as housing and financial assistance. The victim may also be encouraged to take a good self-defense course for protection from the abuser. At any time, if the victim is injured, she should seek medical help and take pictures of bruises or injuries for evidence of the abuse. The victim is also encouraged to seek education from an IPV program and to move to a shelter for safety. An estimated 50 percent of all homeless women and children in the United States are fleeing IPV (Family Violence Prevention Fund, 2008). The nurse should encourage the victim to change regular travel habits, try to receive rides with different people, and shop and bank at different places if she is being stalked. The victim
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patient may be at high risk for abuse, a more detailed assessment should be completed. High-risk triggers for women experiencing IPV may include weight changes, chronic pain, old and unhealed injuries, headaches, blurred vision, tinnitus, dizziness, anxiety, vaginal bleeding or discharge and gastrointestinal symptoms (Zerbe, 1999). One study completed with 370 women, only 3 percent of those women stated that they were asked by a healthcare provided about physical or sexual violence by an intimate partner (Medline Plus, 2008). During the screening, women may not use a direct term of “abuse”; however, nurses should be aware of words that suggest abuse is occurring. Such words or statements may include that the women’s partner “has a temper” or “gets angry easily.” The nurse should then use that term when asking the women to continue the assessment (Valente, 2002). The victim may feel more comfortable with the term of her choice and thus reveal the true extent of the abuse. Screening tools may include the Woman Abuse Screening Tool (WAST) (Brown, Lent, Schmidt, & Sas, 2000), Abuse Risk Inventory, Conflict Tactics Scale (Yegadis, 1989) or the Danger Assessment Scale, (Campbell, 1989). Many health care organizations have position statements and screening guidelines regarding IPV (Rhodes & Levinson, 2003; AWHONN, 2007). If IPV is identified, nurses and other health care professionals have a responsibility to offer referrals to confidential victim and social support resources within the community, regardless of whether or not the victim chooses to report the abuse to law enforcement (AWHONN, 2007). Nurses can also educate their patients using the American Bar Association (2008) recommendation that encourages victims of IPV to protect themselves from harm by removing themselves from the kitchen when an argument may be beginning (see Box 3 for other safety strategies). The kitchen is the room where there are more weapons, such as knives, that the perpetrator may use to harm the victim. Victims are also advised to stay out of bathrooms, closets or small spaces where the abuser can trap the victim. Victims should remove themselves from the home if possible or go to a room with a door or window to escape or lock the abuser outside. Nurses should encourage victims to call 911 in an emergency and to go to their health care provider or nearest emergency room for care when injuries require medical care. Victims may also go to a local women’s shelter or crisis center for housing and counseling or call the National Domestic Violence Hotline (see “Get the Facts”). If the abuser has moved out, the victim should change the locks on doors and get locks for windows. The victim may ask neighbors to call the police if they see the abuser at the victim’s house and the neighbor and the victim may also agree on a signal for the neighbor to call the police. The victim should maintain an unlisted phone number, block caller ID and have an answering machine to screen calls. The victim should be careful if there is a computer in the home because the abuser may be monitoring the victim’s computer activities.
BOX 4 BEING PREPARED Victims of IPV should have copies of these documents to establish housing and financial assistance: • Birth certificates • List of medications and doses • Medical records • Passports • Court papers • Immigration papers
should cancel all bank accounts or credit cards shared with the perpetrator and should open accounts at a different bank. Victims should seek a legal protection order against the abuser and always carry the court order with them. The victim should provide a picture of the abuser to security and friends at work and tell supervisors to attempt to make it harder for the abuser to find the victim. Victims should never eat out alone, including going out for lunch during work. If a security guard is available, the victim should request the guard to walk her to her car or transportation. If the abuser calls the victim at work and leaves a message, the victim should save voicemail and email to provide evidence to give to the police. Nurses treating victims of IPV should describe injuries in detail and use body maps to provide clarification. The nurse should never use the term “choked” as the description of strangulation, because “choking” describes a foreign object caught in the patient’s trachea or esophagus whereas “strangulation” describes an assault that causes the patient harm with a malicious intent to harm the patient. Nurses should document interventions and discharge information clearly to identify treatments and follow-up options provided to the patient.
CONCLUSION Accurate IPV statistics are lacking because nurses and other health professionals may not be screening patients and asking them if abuse is occurring in their relationships. Nurses should ask all patients about questionable injuries and screen for possible abuse regularly. Additional research is required to provide accurate statistics and nurses may assist in educating the community at large about the true magnitude of abuse. IPV is cruelty to another person. This abuse has no excuse. Nurses can make a difference by screening for abuse and providing safety education to the victim; these actions may save the victim’s life as well as the lives of her family members. NWH
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REFERENCES American Bar Association. (2008). Commission on domestic violence. Retrieved March 12, 2008, from http://www.abanet.org/ domviol/home.html. AWHONN. (2007). Position statement: Mandatory reporting of intimate partner violence. Washington, DC: Author. Retrieved March 25, 2008, from http:/ www.awhonn.org/awhonn/binary. content.do?name=Resources/Douments/pdf/5H1_PS_Intimate PartnerViolence.pdf. Bergen, R. (1996). Wife rape: Understanding the response of survivors and service providers. Thousand Oaks, CA: Sage. Brown, J., Lent, B., Schmidt, G., & Sas, G. (2000). Application of the women abuse screening tool and WAST-short in the family practice setting. Journal of Family Practice, 49, 896–903. Campbell, J. (1989). Women’s responses to sexual abuse in intimate relationships. Health Care for Women International, 10, 335–340. Campbell, J., Webster, D., Koziol-McLain, J., Block, C., Campbell, D. Curry, M., et al. (2003). Risks for femicide in abusive relationships: Results from a multisided case control study. American Journal of Public Health, 93, 1089–1097. Center for Policy Research. (1997). The crime of stalking: How big is the problem? Denver, CO: Author. Centers for Disease Control and Prevention. (2003). Costs of intimate partner violence against women in the United States. Retrieved March 12, 2008, from http://www.cdc.gov/ncipc/ pub-res/ipv_cost/IPVBook-Final-Feb18.pdf. Centers for Disease Control and Prevention. (2006). Intimate partner violence: Fact sheet. Retrieved March 12, 2008, from http:// www.cdc.gov/ncipc/dvp/ipv_factsheet.pdf. Coker, A., Davis, K., Arias, I. Desai, S., Sanderson, M. Brandt, H., et al. (2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23, 260–268. Crandall, M., Nathens, A., Kernic, M., Holt, V., & Rivara, F. (2004). Predicting future injury among women in abusive relationships. Journal of Trauma—Injury Infection and Critical Care, 56, 906–912. Family Violence Prevention Fund. (2008). Domestic violence is a serious, widespread social problem in America: The facts. Retrieved March 12, 2008, from http://www.endabuse.org/resourcesfacts/. Fleury, R., Sullivan, C., & Bybee, D. (2000). When ending the relationship does not end the violence: Women’s experiences of violence by former partners. Violence against Women, 6, 1363–1383. Gazmararian, J., Petersen, R., Spitz, A., Goodwin, M., Saltzman, L., & Marks, J. (2000). Violence and reproductive health: current knowledge and future research directions. Maternal and Child Health Journal, 4, 79–84. Hawley, D. (n.d.). Death by strangulation by Dr. Dean Hawley. Nashville, TN: Wynn Consulting. Retrieved March 12, 2008, from http://www.markwynn.com/dv/Death%20by%20 Strangulation%20-%20Dr.%20Dean%20Hawley.pdf Heise, L., & Garcia-Moreno, C. (2002). Violence by intimate partners. In E. Krug, L. Dahlberg, & J. Mercy (Eds.), World report on violence and health (pp. 87–121). Geneva, Switzerland: World Health Organization.
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http://www.cdc.gov/ncipc/dvp/IPV/default.htm DomesticViolence.org
http://www.domesticviolence.org/ Family Violence Prevention Fund
http://www.endabuse.org/
http://www.nlm.nih.gov/medlineplus/ domesticviolence.html National Coalition Against Domestic Violence
http://www.ncadv.org/ National Domestic Violence Hotline
1-800-799-SAFE / 1-800-787-3224 (TTY) http://www.ndvh.org/ U.S. Department of Justice
http://www.ovw.usdoj.gov/domesticviolence.htm WomensHealth.gov
http://www.4women.gov/violence/types/ domestic.cfm World Health Organization
http://www.who.int/entity/violence_injury_ prevention/violence/world_report/factsheets/ en/ipvfacts.pdf
McFarlane, J., Parker, B., & Soeken, K. (1996). Abuse during pregnancy: Association with maternal health and infant birth weight. Nursing Research, 45, 32–37. Medline Plus. (2008). Domestic violence. Retrieved March 25, 2008, from http://www.nlm.nih.gov/medlineplus/domesticviolence.html. Nelson, H., Nygren, P., McInerney, Y., & Klein, J. (2004). Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140, 387–396. Parkinson, G., Adams, R., & Emerling, F. (2001). Maternal domestic violence screening in an office-based pediatric practice. Pediatrics, 108, E43. Plichta, S. (2004). Intimate partner violence and physical health consequences: Policy and practice implication. Journal of Interpersonal Violence, 19, 1296–1323. Rennison, C. (2003). Intimate partner violence, 1993-2001. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, Publication No. NCJ197838. Rhodes, K., & Levinson, W. (2003). Interventions for intimate partner violence against women. JAMA, 289, 601–605. Roberts, T., Klein, J., & Fisher, S. (2003). Longitudinal effect of intimate partner abuse on high risk behavior among adolescents. Archives of Pediatrics and Adolescent Medicine, 157, 875–881. Roberts, R., & Petretic-Jackson, P. (1998). Assessment measures for battered women. In: A. W. Burgess (Ed.), Advanced practice psychiatric nursing. Stamford, CT: Appleton & Lange. Strack, G., & McClane, G. (1999). How to improve your investigation and prosecution of strangulation cases. Austin, TX: National Center of Domestic and Sexual Violence. Retrieved March 12, 2008, from http://www.ncdsv.org/images/strangulation_article.pdf. The National Domestic Violence Hotline. (2008). National domestic violence hotline. Retrieved March 12, 2008, from http://www.ndvh.org. Tjaden, P., & Thoennes, N. (2000a). Extent, nature and consequences of intimate partner violence: findings from the National Violence Against Survey. Washington, DC: National Institute of Justice and the Centers for Disease Control and Prevention. Tjaden, P., & Thoennes, N. (2000b). Full report of the prevalence, incidence, and consequences of violence against women: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice and the Centers for Disease Control and Prevention. U.S. Department of Justice. (2007). Homicide trends in the United States. Retrieved March 12, 2008, from http://www.ojp.gov/bjs/ homicide/intimates.htm. Valente, S. (2002). Evaluating intimate partner violence. Journal of the American Academy of Nurse Practitioners, 14, 505–516.
Johnson, M., & Leone, J. (2005). The differential effects of intimate terrorism and situational couple violence. Journal of Family Issues, 26, 322–349. Kearney, M. (2001). Enduring love: A formal theory of women’s experience of domestic violence. Research in Nursing and Health, 24, 270–282.
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Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing: A clinical approach. St. Louis, MO: Saunders Elsevier. Yegadis, K. (1989). Women’s mental health in primary care. Philadelphia: W. B. Saunders. Zerbe, K. J. (1999). Trauma and violence. In: Women’s mental health in primary care. Philadelphia: W. B. Saunders.
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Mahoney, B. (2006). Reducing barriers against routine screening for intimate partner violence. American Journal for Nurse Practitioners, 10(10), 45–58.
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Get the Facts
CNE
Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.
http://JournalsCNE.awhonn.org
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Coker et al. (2002) estimate that which percentages of women and men will experience IPV in their lifetimes? a. 11 percent of women and 12 percent of men b. 20 percent of women and 18 percent of men c. 29 percent of women and 22 percent of men
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Signs of IPV include: a. frequent rescheduling of health care visits b. overuse of health services c. the intimate partner driving the patient to health visits
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Documents recommended to be carried by victims of IPV include: a. car titles b. medical records c. mortgage papers or housing rental agreements Recommended approaches to screening for IPV include: a. reading non-verbal cues in order to decide if a woman should be screened for IPV b. using indirect terms to refer to abuse c. using screening tools to decide if a woman should be asked about IPV at all Safety strategies nurses can recommend to victims of IPV include: a. buying a new car b. changing jobs c. shopping and banking at different places Strangulation and choking describe two different actions. Which statement best describes this difference? a. Choking describes an assault that is intended to cause the victim harm, whereas strangulation describes a foreign object lodged in the victim’s throat. b. Strangulation describes an assault that is intended to cause the victim harm, whereas choking describes a foreign object lodged in the victim’s throat. c. Strangulation describes unintentional harm, whereas choking causes intentional harm. Safety recommendations for computer use for victims of IPV include: a. avoiding identity theft by using secure sites b. changing online passwords c. investing in anti-virus software
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8.
Which of the following actions is an example of social abuse? a. forcing undesired pregnancy or rapidly repeated pregnancies b. making the victim account for money spent c. requiring the victim to ask permission before leaving the house
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For which race and gender groups (across all relationship categories) did the intimate homicide rate fall the most between 1976 and 2004? a. black females and males b. Hispanic females and males c. white females and males
10. IPV accounts for which percentage of homicides among pregnant women? a. 22 percent b. 31 percent c. 39 percent 11. Strategies of safety that the nurse may educate the victim to do when an argument is beginning may include: a. changing the subject matter of the argument b. encouraging the abuser to calm down c. moving out of a kitchen or bathroom 12. Which of the following race and gender groups have the highest prevalence of IPV? a. American Indian or Alaska Native women and men b. Asian women and men c. White women and men 13. IPV is an abusive relationship in which the perpetrator desires to have: a. a sense of importance to the victim b. financial security c. power and control over the victim 14. What is the estimated percentage of homeless women and children in the U.S. who are fleeing IPV? a. 25 percent b. 50 percent c. 75 percent 15. Which type of abuse is stalking? a. economic b. physical c. social
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Carol L. Krieger, APRN, MSN, BC
Objectives Upon completion of this activity, the learner will be able to:
1. Differentiate between the different types of intimate partner violence (IPV). 2. Cite statistics and trends regarding IPV, including prevalence rates, differences among different racial and ethnic groups, and economic implications. 3. Identify universal IPV screening and assessments pertinent for victims of IPV. 4. Describe education and safety information nurses can provide to victims of IPV.
Intimate partner violence (IPV), also called domestic violence (DV), is a health care problem that physically and mentally traumatizes women, men and children, and leads to chronic health problems for the victims. Victims of IPV may undergo unnecessary diagnostic testing for chronic physical symptoms that may be due to physical and emotional abuse (Mahoney, 2006). The physical abuse may be treated by the health care professional; however, the nurse must also address the underlying causes of these injuries and provide the victim with safety education. The Centers for Disease Control and Prevention (CDC, 2003) state that IPV is a serious preventable public health problem affecting more than 32 million Americans or more than 10 percent of the U.S. population (Tjaden & Thoennes, 2000a). IPV doesn’t always leave the victim with visible scars. The perpetrator may abuse the victim with a smile upon their face and the perpetrator may feel that they are entitled to abuse others. The scars are felt much deeper in the victim’s heart and soul.
Continuing Nursing Education (CNE) Credit
STATISTICS
A total of 2 contact hours may be earned as CNE credit for reading “Intimate Partner Violence: A Review for Nurses” and for completing an online post-test and participant feedback form.
Statistics about IPV are difficult to determine because it’s estimated that only 20 percent to 50 percent of the assaults are reported to the police (The National Domestic Violence Hotline, 2008). Tjaden and Thoennes (2002a) estimate that only 25 percent of all physical assaults against women, and fewer assaults against men, are reported to the police. Coker et al. (2002) estimate that 29 percent of all women and 22 percent of all men will experience physical, sexual or psychological abuse in their lifetime. Many experts believe the true magnitude of the abuse is greatly underestimated. According to the CDC (2006), each year women experience about 4.8 million intimate partner–related physical assaults and rapes, and men are the victims of about 2.9 million intimate partner–related physical assaults. IPV resulted in 1,544 deaths in 2004 (CDC, 2006). Of these deaths, 25 percent were males and 75 percent were females. These statistics translate into economic effects, as well. The CDC (2003) estimated that in 2003, the economic costs of IPV exceeded $8.3 billion. Persons affected by IPV have a productivity loss of 8 million days of paid work (the equivalent of 32,000 full-time jobs) and 5.6 million days of unpaid household work each year (CDC, 2003). Abusers may not allow victims to work or attend college. Women who experience IPV are more likely to be unemployed, have health problems and receive public assistance than are women who are not victims of IPV. Additional work may be required of coworkers due to victims’ absenteeism. Tax dollars are used to support programs to assist victims.
To take the test and complete the participant feedback form, please visit http://JournalsCNE. awhonn.org. Certificates of completion will be issued on receipt of the completed participant feedback form, application and processing fees. AWHONN is accredited as a provider of continuing nursing education by the American Credentialing Center’s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN also holds California and Alabama BRN numbers: California CNE provider #CEP580 and Alabama # ABNP0058.
Carol L. Krieger, APRN, MSN, BC, is a visiting assistant professor at the University of Toledo, a psychiatric nurse practitioner at Harbor Behavioral Healthcare, and coordinator of the Domestic Violence and Sexual Assault Nurse Examinator in the Emergency Department at the University of Toledo Medical Center, Toledo, OH. The author reports no conflicts of interest or financial relationships relevant to this article. Address correspondence to: [email protected]. DOI: 10.1111/j.1751-486X.2008.00327.x Opening photo © Fotolia VI / Fotolia.com
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DEFINITIONS IPV or DV may be defined as any behavior that causes physical, mental, sexual, emotional or social isolation or abuse to the victim, who is in an intimate relationship with the abuser (Family Violence Prevention Fund, 2008). Domestic violence is considered an older term, whereas intimate partner violence
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IMPACT ON INDIVIDUALS, FAMILIES AND SOCIETY IPV affects females and males of all ages and racial, educational, cultural and economic backgrounds. The groups found to have the highest prevalence of IPV are American Indian and Alaskan Native women and men, black women and Hispanic women (Tjaden & Thoennes, 2000b). IPV includes violence within same-sex relationships and among family members. The majority of abuse victims are women (Rennison, 2003). Johnson and Leone (2005) state that victims of repeated violence over time
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Children who live in a household in which IPV occurs are at greater risk of the following: • Psychiatric disorders • Developmental problems • School failure • Violence against others • Low self-esteem
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BOX 1 RISKS FOR CHILDREN
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experience more serious injuries than do is considered a more modern term e victims of one-time abuse incidents. Young that recognizes that intimate partv e c iolen partner v te a women and people closer to the poverty ners don’t always live within the w m c ti sti • In lled dome a c o ls a line are affected more often than any same household. The terms are used li ), (IPV mpasses o c n e , e c n other population (Heise & Garcia-Moreno, interchangeably in this article. o viole exual, mental, s buse. 2002). Children who live in a household in A comparison of the definition 2 physical, a economic which their mothers are being abused are of the term “intimate partner” was w social and ’t often don V IP f o 57 times more likely to be harmed (Parkincompleted in a Midwestern state, an 5 s • Victim . e s u b a e Eastern state and Western state. All sson, Adams, & Emerling, 2001) (see Box 1). report th for IPV n e re Perpetrators of IPV cause instability three states defined an intimate partP c s n a c t • Nurses tims abou ic v l e within their families while causing physical ner as a current or former spouse or w s n u o and can c . s e rc u o s and psychological damage. a current or former cohabitant, and a re safety and IPV can be difficult to identify bealso included dating and engagement relationships. Additionally, ccause it often occurs in private and bein all three states “intimates” were ccause victims are often reluctant to report also defined as parents of children iincidents to anyone because of shame together and those persons related aand fear of reprisal by family members and friends. Victims who stay with their by consanguinity or affinity, which abuser are often ostracized by family members and friends who literally means “blood relationship.” The East Coast state indon’t understand the psychological attachment between the cluded in the definition those persons in relationships who may victim and the abuser. be sexually consummated or not, as well as in gay, lesbian, biThe U.S. Department of Justice (2007) reports that female sexual and transgendered relationships. victims are substantially more likely than male victims to be In IPV, there exists an abusive relationship in which the perkilled by an intimate partner. Male abusers kill their female petrator desires to have power and control over the victim; IPV partners four times more often than female abusers kill males is not about anger but rather the desire to instill fear in the vicinvolved in IPV. Between 1976 and 2004, a higher number tim. The perpetrator gradually creates fear in the victim in which of homicides involved spouses; however, in recent years the there is a slow disintegration of a victim’s sense of self and selfnumber of deaths by boyfriends and girlfriends have increased image. This process increases the victim’s feelings of devaluing (Rennison, 2003). The intimate homicide rate between 1976 and isolation. Victims are more likely to accept this abuse if they and 2004 fell by 82 percent for black males and by 56 percent were exposed to verbal, physical or sexual victimization in their for black females, across all relationship categories (Rennison, childhood (CDC, 2006). Secrecy is an abuser’s best protection. 2003). The rate declined by 55 percent for white males and only A victim of IPV may display low self-esteem, depression, an5 percent for white females (U.S. Department of Justice). More tisocial behavior, inability to trust, fear of intimacy and suicidal than two-thirds of spouse and ex-spouses victims of IPV were behaviors due to anxiety related to the abuse and fear of the killed by guns between 1976 and 2004. Female abusers were discovery of the abuse (Bergen, 1996; Coker et al., 2002; Heise more likely to kill their boyfriends with knives than were any & Garcia-Moreno, 2002; Roberts, Klein, & Fisher, 2003). Older other group of intimates. Large gaps remain in IPV research women are more likely to experience violence for a longer time related to culture and ethnicity and these areas require further and to remain in a violent relationship than are younger women, exploration. because older women may feel they have fewer opportunities because of their age. Women who have been in a long-term abusive relationship have a higher incidence of chronic health and mental health problems (Johnson & Leone, 2005).
PHYSICAL ABUSE Physical abuse includes the abuser spitting, kicking, punching, grabbing, slapping or strangulating the victim. Women with a history of IPV report 60 percent higher rates of all health problems than do women with no history of abuse (Campbell et al., 2003). The IPV victim may arrive in the doctor’s office or emergency room with vague, chronic, non-specific complaints and a history of overuse of health services or unexplainable injuries such as bruises or fractures. Advanced practice nurses should consider their patients’ chronic complaints as possible abuse symptoms. Women may undergo unneeded diagnostic testing to try to elucidate the cause of these chronic conditions (Mahoney, 2006). See Box 2 for signs of IPV. The abuser may insist on staying with the victim during the health care examination and refuse to leave the victim’s side. The abuser may appear to act overly attentive toward the victim to discourage the victim’s disclosure of the abuse to the health care provider. The abuser may insist on informing the care provider how the victim was injured and may not allow the victim to talk to the care provider in private; the information of how the victim was injured may not match the victim’s injuries. Victims may have repeated accidental injuries and delay receiving treatment for serious injuries. Crandall, Nathens, Kernic, Holt, and Rivara (2004) found that 93 percent of female IPV victims had at least one previous injury visit to a health care facility, and 44 percent of women murdered during IPV had visited an emergency department within two years of being murdered. Another form of physical abuse is strangulation. Strangulation is a form of asphyxia or lack of oxygen caused by a forced pressure injury to the victim’s neck. This injury may be caused by the hand (manual) or by a ligature, such as a rope or clothing. Ten percent of the violent deaths in the United States are due to strangulation, with six females being killed for every one male (Strack & McClane, 1999). The patterns of injury, such as bruising or ligature marks, may allow the care provider to determine if the blunt force trauma was caused by strangulation, hanging or traumatic blows to the neck. Hawley (n.d.) states the immediate death from strangulation is usually caused by the pressure on the carotid arteries, which prevents blood flow to the brain or pressure on the jugular veins, which prevents blood flow from the brain. Strack and McClane state that an 11-pound pressure placed on both carotid arteries for 10 seconds will cause the victim to become unconscious. If this pressure is released, the victim will gain consciousness in 10 seconds. Strack and McClane (1999) found that victims who were strangled may have physical evidence of an injury to the neck in only 50 percent of strangulation cases and in only 35 percent of minor cases. Visible evidence such as red marks, bruises or rope burns may be found in only 15 percent of strangulation cases (Strack & McClane). Only three percent of victims who were strangled sought medical care (Strack & McClane). These victims usually sought care only due to a complaint of
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persistent throat pain, voice changes or trouble swallowing. Strangulations that do not result in immediate death must be investigated by the care provider carefully due to possible hyoid fracture, which results in approximately one-third of all fatal strangulations (Hawley, n.d.). The hyoid bone is a small horseshoe-shaped bone in the neck that supports the tongue. Because this injury does not always provide evidence, the victim may not be admitted for observation and may be discharged to their home. Breathing changes may initially be mild; however, underlying injuries such as injuries to the hyoid bone or underlying structures may kill the victim up to 36 hours later due to asphyxiation (Strack & McClane).
MENTAL OR EMOTIONAL ABUSE Mental or emotional abuse such as coercion, threats and stalking may also be inflicted on abuse victims by perpetrators. According to Tjaden and Thoennes (2000a), more than 1 million women and 371,000 men are stalked by intimate partners. The perpetrator may verbally abuse the victim with put-downs, insults, criticism or name-calling. The perpetrator may intimidate the victim by giving the victim certain looks or gestures to instill fear. The perpetrator may coerce the victim by threatening to harm children, family members and pets. Abusers often destroy the victim’s property, abuse their pets or display weapons to force the victim into submitting to the perpetrator’s wishes. The abuser may convince children to view the victim as having caused the abuse by causing the perpetrator to become angry; thus, the children may blame the victim. Abusers commonly play the “blame game” with those they abuse. The abuser may blame the victim for being clumsy and may deny harming the victim. The abuser may minimize the victim’s injuries and provide excuses for the abusive behavior. The abuser may attempt to convince others that the victim is incompetent or crazy and is not to be believed or taken seriously.
SEXUAL ABUSE Sexual abuse may include the perpetrator forcing sexual intercourse or sexual activities against the victim’s will. Rapes and
BOX 2 SIGNS OF IPV • Overuse of health services • Vague, non-specific complaints • Missed appointments • Unexplainable injuries • Untreated serious injuries • Injuries not matching the description • Intimate partner never leaving the patient’s side • Intimate partner insisting on telling the story of the injury
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Social abuse may include isolating or limiting the victim’s contacts with family and friends and requiring the victim to obtain permission to leave the house. The abuser may not allow the victim to attend work or school and may control the victim’s social activities; an abuser might also check the odometer of the victim’s car as a way to “keep tabs” on the victim and might also require the victim to provide a detailed account of any time spent away from the abuser. The perpetrator may restrain the victim’s access to medical services or cause the victim to miss medical appointments, which causes strained relationships with health care providers, employers, friends and family members (Heise & Garcia-Moreno, 2002; Plichta, 2004). The perpetrator may damage the victim’s reputation and intimidate the victim’s
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IPV is a serious preventable public health problem affecting more than 32 million Americans or more than 10 percent of the U.S. population. 371,000 men are stalked by IPV abusers. Tjaden and Thoennes (2000b) estimate that only 50 percent of stalking activity against women is reported to the police. The Center for Policy Research (1997) states that 80 percent of women who are stalked by former husbands are physically assaulted and 30 percent are sexually assaulted. Stalking must be taken as a serious threat and the victim should be encouraged to report this abuse to the police.
ECONOMIC ABUSE Economic abuse may include the perpetrator controlling the victim’s finances, refusing to share money, making the victim account for money spent and not allowing the victim to work outside the home. The abuser desires that the victim be emotionally and financially dependent on the abuser. The abuser may also try to sabotage the victim’s work performance by forcing her to miss work or by calling the victim frequently at work and causing her to lose her job. The American Bar Association (2008) reports that 70 percent of IPV victims are employed and more than 70 percent of them report that their abusers harass them at work either over the telephone or in person. The American Bar Association reports that perpetrators cause more than 60 percent of their victims to be either late to and/or absent from work.
PHASES OF ABUSE The IPV abuser exhibits three phases of abuse (Varcarolis, Carson, & Shoemaker, 2006). Phase one includes a tensionbuilding phase that may include the abuser calling the victim inappropriate names and pushing or shoving the victim. During the first phase, the victim attempts to deny that the abuse will happen and tries to please the abuser to prevent abuse; however, this often only postpones rather than prevents the abuse.
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SOCIAL ABUSE
family and friends. The perpetrator causes a breakdown in the victim’s relationships that could provide emotional support for the victim. McFarlane, Parker, and Soeken (1996) found that 50 percent of men who frequently assault their wives also assault their children. Nelson, Nygren, McInerney, and Klein (2004) report that children who witness IPV are at a greater risk of developing psychiatric disorders, developmental problems, school failure, violence against others and low self-esteem. Social abuse may also include the abuser stalking the victim. The CDC (2003) has reported that one million women and
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sexual assaults committed by strangers are more likely to be reported than are rapes and sexual assaults committed by an intimate partner (Rennison, 2003). In one study conducted between 1992 and 2000, 41 percent of rapes and sexual assaults committed by strangers were reported, whereas only 24 percent of rapes and sexual assaults committed by an intimate partner were reported (Rennison, 2003). Sexual abuse may include the victim being forced to participate in early sexual initiation, decreased condom use or unprotected sexual intercourse, having multiple sexual partners, and trading sex for food, money or other items (CDC, 2003). This sexual activity may increase the victim’s chances of being exposed to sexually transmitted infections, including human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). Sexual abuse can also include forcing an undesired pregnancy or forcing pregnancies to occur rapidly one after another. Pregnancy is a particularly dangerous time for any abused woman. Not only is the woman’s health and life at risk, but also the health and life of the fetus. IPV may begin or increase with pregnancy because the abuser may feel trapped in the relationship and feel the added pressure to provide emotional and financial support for the mother and child. A study completed by Gazmararian et al. (2000) found that 324,000 pregnant women are abused by their partner at least once during their pregnancy each year. The Family Violence Prevention Fund states that IPV accounts for 31 percent of the homicides among pregnant women and is the leading cause of traumatic death for pregnant and postpartum women in the United States. Tjaden and Thoennes (2000a) estimate that among women between the ages of 20 and 44, only 20 percent of IPV rapes and sexual assaults are reported to the police. The CDC (2006) report that 1.5 million women and 800,000 men are raped or physically assaulted each year. The CDC further clarifies these numbers as 47 IPV assaults per 1,000 women and 32 assaults per 1,000 men. Tjaden & Thoennes (2000a) have reported that Hispanic women are more likely than non-Hispanic women to report intimate partner rape.
The second phase is the act of the abuser inflicting violence on the victim (Varcarolis, Carson, & Shoemaker, 2006). In this phase, abusers make victims feel that they’ve angered the abuser, making victims feel responsible for the abuse. Victims often feel that if they were “smarter,” then the abuse would not have happened. The third phase is often referred to as the “honeymoon” (Varcarolis, Carson, & Shoemaker, 2006), in which the abuser is overly apologetic and expresses guilt and shame for the abuse. Abusers often promise victims that they won’t harm them or their family or pets again. The abuser may beg the victim for forgiveness using the victim’s religious or cultural beliefs to encourage the victim to forgive the abuser. The victim may believe the abuser’s words and intent to change and return to the abuser due to religious and cultural convictions. The abuser may also offer the victim gifts or a promise to stop abusing. Abusers may threaten to commit suicide or kill others if victims don’t return to them. Once abusers have apologized to victims, they begin to blame the victim, saying that the abuse wouldn’t have happened if the victim hadn’t “said or done something” to make the abuser angry. Women who have separated from a violent partner often remain at risk (Campbell et al., 2003; Fleury, Sullivan, & Bybee, 2000).
UNDERSTANDING VICTIMS’ ACTIONS Kearney (2001) completed research in women between the ages of 16 and 67 on the rationalizations of why victims remain and even return to their abusers, and detected four phases of recovery for the victim. The first phase includes a theme of feeling an “enduring love” and obligation to the relationship. The victim
Women who have separated from a violent partner often remain at risk. enters into a relationship to fulfill the desire of loving and being loved and believes this relationship to be forever. Many victims may have religious values or live in a culture that doesn’t advocate separation and divorce, and may fear the mental anguish of being separated from their family and friends. Family members and friends may not believe that the victim has been abused or may minimize the abuse and be unwilling to assist the victim in separating from the abuser. The victim may have fear of the disclosure of the abuse and minimize the abuse. Victims may feel guilt and shame and blame themselves for the abuse and may feel the need to protect abusers to maintain their love and devotion. The second phase, according to Kearney (2001), includes the theme of “the more I do, the worse that I am,” which describes the victim as trying to meet the abuser’s needs in every way possible, despite how unpredictable the abuser’s behaviors are. Abuse becomes a regular part of the relationship and the victim can no longer pacify the abuser to avoid the abuse.
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Victims begin to doubt themselves and lose their identity. Victims restrain their emotions and reactions to avoid abuse. Victims often display harmful behaviors such as substance abuse, alcoholism and suicide attempts to cope with the emotional strain of the abuse (CDC, 2003). They may also use coping behaviors, such as practicing detrimental dieting behaviors such as fasting, vomiting, abusing diet pills and overeating to regain a small amount of control over their lives (CDC, 2003). The third phase of the violent relationship as defined by Kearney (2001) includes a theme of “I’ve had enough” (2001). This is the stage when the victim has determined that the relationship is abusive and has decided not to continue to tolerate the abuse. An episode such as harming the children may incite the victim to take action to leave the abuser. The victim may have fear of the unknown and of being alone and may lack knowledge regarding what to do and where to go for safety. This is an opportune time for the nurse to provide information and education for the victim to leave the abuser if they are receiving treatment. Nurses should learn about services in their area that may assist the victim and provide safety information. Nurses should advocate posting literature about abuse in the community and providing victims with telephone help numbers and other resources. Many IPV agencies provide cards with telephone numbers in public restrooms, as the restroom may be the only area that the perpetrator may allow the victim to be by themselves. During this phase, the victim is aware and open to starting a new life without the abuser. Valente (2002) has documented that most women will not stay in abusive relationships and will leave within the first two years; however, the women may make several attempts of leaving the relationship until the final separation is completed. Wives who leave their husbands had a two to four times greater risk of being killed by their spouse after a separation (Valente). The fourth and final phase of the violent relationship is defined by Kearney (2001) as “I was finding me.” In this phase, the victim has established a life separate from the abuser. The victim may deplete resources while being separated from the abuser and may begin to question her decision of leaving the abuser. Victims may have little experience with economic independence and may think that they don’t have the skills to support themselves and their children. This is a time when women need support and encouragement to remain separate from the abuser. The victim is in a time of self discovery and recovery and is going from a “being a victim to becoming survivor.”
IMPLICATIONS FOR NURSING PRACTICE Screening for IPV should become a routine part of health care assessment in all females over the age of 14, regardless of the presenting problem (Roberts & Petretic-Jackson, 1998). The initial screening should include general questions and should be conducted on a one-to-one basis within the health care setting (Valente, 2002). If the screening tool suggests that the
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BOX 3 SAFETY STRATEGIES Victims of IPV should try to maintain the following safety strategies: • Always be aware of surroundings • Minimize time in kitchens, bathrooms and closets when abuser is near • Shop and bank at different places • Drive to work multiple ways • Get a protection order • Never lunch alone • Cancel joint credit cards and old bank accounts with abuser • Provide a picture of abuser to security at workplace • Be escorted by workplace security to car or transportation • When in danger, go to a place of safety and call 911 • Change locks on house if abuser has moved out • Get unlisted telephone number • Block caller ID The victim may consider using a friend’s computer or a computer at the library for safety to avoid the abuser having access to the email addresses of the victim’s family members and friends. The victim should be encouraged to change online passwords and create a new email account to avoid the abuser’s harassment. Many agencies encourage the victim to pack a bag with important items that will be needed if she must escape from the abuser quickly. This bag may be placed in a safe place or given to a friend or relative for the safe keeping. This bag may include extra car keys, medications, credit cards, court papers, passports, birth certificates, medical records and immigration papers or copies of these documents (see Box 4). The victim will need these documents to establish stability, such as housing and financial assistance. The victim may also be encouraged to take a good self-defense course for protection from the abuser. At any time, if the victim is injured, she should seek medical help and take pictures of bruises or injuries for evidence of the abuse. The victim is also encouraged to seek education from an IPV program and to move to a shelter for safety. An estimated 50 percent of all homeless women and children in the United States are fleeing IPV (Family Violence Prevention Fund, 2008). The nurse should encourage the victim to change regular travel habits, try to receive rides with different people, and shop and bank at different places if she is being stalked. The victim
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patient may be at high risk for abuse, a more detailed assessment should be completed. High-risk triggers for women experiencing IPV may include weight changes, chronic pain, old and unhealed injuries, headaches, blurred vision, tinnitus, dizziness, anxiety, vaginal bleeding or discharge and gastrointestinal symptoms (Zerbe, 1999). One study completed with 370 women, only 3 percent of those women stated that they were asked by a healthcare provided about physical or sexual violence by an intimate partner (Medline Plus, 2008). During the screening, women may not use a direct term of “abuse”; however, nurses should be aware of words that suggest abuse is occurring. Such words or statements may include that the women’s partner “has a temper” or “gets angry easily.” The nurse should then use that term when asking the women to continue the assessment (Valente, 2002). The victim may feel more comfortable with the term of her choice and thus reveal the true extent of the abuse. Screening tools may include the Woman Abuse Screening Tool (WAST) (Brown, Lent, Schmidt, & Sas, 2000), Abuse Risk Inventory, Conflict Tactics Scale (Yegadis, 1989) or the Danger Assessment Scale, (Campbell, 1989). Many health care organizations have position statements and screening guidelines regarding IPV (Rhodes & Levinson, 2003; AWHONN, 2007). If IPV is identified, nurses and other health care professionals have a responsibility to offer referrals to confidential victim and social support resources within the community, regardless of whether or not the victim chooses to report the abuse to law enforcement (AWHONN, 2007). Nurses can also educate their patients using the American Bar Association (2008) recommendation that encourages victims of IPV to protect themselves from harm by removing themselves from the kitchen when an argument may be beginning (see Box 3 for other safety strategies). The kitchen is the room where there are more weapons, such as knives, that the perpetrator may use to harm the victim. Victims are also advised to stay out of bathrooms, closets or small spaces where the abuser can trap the victim. Victims should remove themselves from the home if possible or go to a room with a door or window to escape or lock the abuser outside. Nurses should encourage victims to call 911 in an emergency and to go to their health care provider or nearest emergency room for care when injuries require medical care. Victims may also go to a local women’s shelter or crisis center for housing and counseling or call the National Domestic Violence Hotline (see “Get the Facts”). If the abuser has moved out, the victim should change the locks on doors and get locks for windows. The victim may ask neighbors to call the police if they see the abuser at the victim’s house and the neighbor and the victim may also agree on a signal for the neighbor to call the police. The victim should maintain an unlisted phone number, block caller ID and have an answering machine to screen calls. The victim should be careful if there is a computer in the home because the abuser may be monitoring the victim’s computer activities.
BOX 4 BEING PREPARED Victims of IPV should have copies of these documents to establish housing and financial assistance: • Birth certificates • List of medications and doses • Medical records • Passports • Court papers • Immigration papers
should cancel all bank accounts or credit cards shared with the perpetrator and should open accounts at a different bank. Victims should seek a legal protection order against the abuser and always carry the court order with them. The victim should provide a picture of the abuser to security and friends at work and tell supervisors to attempt to make it harder for the abuser to find the victim. Victims should never eat out alone, including going out for lunch during work. If a security guard is available, the victim should request the guard to walk her to her car or transportation. If the abuser calls the victim at work and leaves a message, the victim should save voicemail and email to provide evidence to give to the police. Nurses treating victims of IPV should describe injuries in detail and use body maps to provide clarification. The nurse should never use the term “choked” as the description of strangulation, because “choking” describes a foreign object caught in the patient’s trachea or esophagus whereas “strangulation” describes an assault that causes the patient harm with a malicious intent to harm the patient. Nurses should document interventions and discharge information clearly to identify treatments and follow-up options provided to the patient.
CONCLUSION Accurate IPV statistics are lacking because nurses and other health professionals may not be screening patients and asking them if abuse is occurring in their relationships. Nurses should ask all patients about questionable injuries and screen for possible abuse regularly. Additional research is required to provide accurate statistics and nurses may assist in educating the community at large about the true magnitude of abuse. IPV is cruelty to another person. This abuse has no excuse. Nurses can make a difference by screening for abuse and providing safety education to the victim; these actions may save the victim’s life as well as the lives of her family members. NWH
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REFERENCES American Bar Association. (2008). Commission on domestic violence. Retrieved March 12, 2008, from http://www.abanet.org/ domviol/home.html. AWHONN. (2007). Position statement: Mandatory reporting of intimate partner violence. Washington, DC: Author. Retrieved March 25, 2008, from http:/ www.awhonn.org/awhonn/binary. content.do?name=Resources/Douments/pdf/5H1_PS_Intimate PartnerViolence.pdf. Bergen, R. (1996). Wife rape: Understanding the response of survivors and service providers. Thousand Oaks, CA: Sage. Brown, J., Lent, B., Schmidt, G., & Sas, G. (2000). Application of the women abuse screening tool and WAST-short in the family practice setting. Journal of Family Practice, 49, 896–903. Campbell, J. (1989). Women’s responses to sexual abuse in intimate relationships. Health Care for Women International, 10, 335–340. Campbell, J., Webster, D., Koziol-McLain, J., Block, C., Campbell, D. Curry, M., et al. (2003). Risks for femicide in abusive relationships: Results from a multisided case control study. American Journal of Public Health, 93, 1089–1097. Center for Policy Research. (1997). The crime of stalking: How big is the problem? Denver, CO: Author. Centers for Disease Control and Prevention. (2003). Costs of intimate partner violence against women in the United States. Retrieved March 12, 2008, from http://www.cdc.gov/ncipc/ pub-res/ipv_cost/IPVBook-Final-Feb18.pdf. Centers for Disease Control and Prevention. (2006). Intimate partner violence: Fact sheet. Retrieved March 12, 2008, from http:// www.cdc.gov/ncipc/dvp/ipv_factsheet.pdf. Coker, A., Davis, K., Arias, I. Desai, S., Sanderson, M. Brandt, H., et al. (2002). Physical and mental health effects of intimate partner violence for men and women. American Journal of Preventive Medicine, 23, 260–268. Crandall, M., Nathens, A., Kernic, M., Holt, V., & Rivara, F. (2004). Predicting future injury among women in abusive relationships. Journal of Trauma—Injury Infection and Critical Care, 56, 906–912. Family Violence Prevention Fund. (2008). Domestic violence is a serious, widespread social problem in America: The facts. Retrieved March 12, 2008, from http://www.endabuse.org/resourcesfacts/. Fleury, R., Sullivan, C., & Bybee, D. (2000). When ending the relationship does not end the violence: Women’s experiences of violence by former partners. Violence against Women, 6, 1363–1383. Gazmararian, J., Petersen, R., Spitz, A., Goodwin, M., Saltzman, L., & Marks, J. (2000). Violence and reproductive health: current knowledge and future research directions. Maternal and Child Health Journal, 4, 79–84. Hawley, D. (n.d.). Death by strangulation by Dr. Dean Hawley. Nashville, TN: Wynn Consulting. Retrieved March 12, 2008, from http://www.markwynn.com/dv/Death%20by%20 Strangulation%20-%20Dr.%20Dean%20Hawley.pdf Heise, L., & Garcia-Moreno, C. (2002). Violence by intimate partners. In E. Krug, L. Dahlberg, & J. Mercy (Eds.), World report on violence and health (pp. 87–121). Geneva, Switzerland: World Health Organization.
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http://www.cdc.gov/ncipc/dvp/IPV/default.htm DomesticViolence.org
http://www.domesticviolence.org/ Family Violence Prevention Fund
http://www.endabuse.org/
http://www.nlm.nih.gov/medlineplus/ domesticviolence.html National Coalition Against Domestic Violence
http://www.ncadv.org/ National Domestic Violence Hotline
1-800-799-SAFE / 1-800-787-3224 (TTY) http://www.ndvh.org/ U.S. Department of Justice
http://www.ovw.usdoj.gov/domesticviolence.htm WomensHealth.gov
http://www.4women.gov/violence/types/ domestic.cfm World Health Organization
http://www.who.int/entity/violence_injury_ prevention/violence/world_report/factsheets/ en/ipvfacts.pdf
McFarlane, J., Parker, B., & Soeken, K. (1996). Abuse during pregnancy: Association with maternal health and infant birth weight. Nursing Research, 45, 32–37. Medline Plus. (2008). Domestic violence. Retrieved March 25, 2008, from http://www.nlm.nih.gov/medlineplus/domesticviolence.html. Nelson, H., Nygren, P., McInerney, Y., & Klein, J. (2004). Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140, 387–396. Parkinson, G., Adams, R., & Emerling, F. (2001). Maternal domestic violence screening in an office-based pediatric practice. Pediatrics, 108, E43. Plichta, S. (2004). Intimate partner violence and physical health consequences: Policy and practice implication. Journal of Interpersonal Violence, 19, 1296–1323. Rennison, C. (2003). Intimate partner violence, 1993-2001. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics, Publication No. NCJ197838. Rhodes, K., & Levinson, W. (2003). Interventions for intimate partner violence against women. JAMA, 289, 601–605. Roberts, T., Klein, J., & Fisher, S. (2003). Longitudinal effect of intimate partner abuse on high risk behavior among adolescents. Archives of Pediatrics and Adolescent Medicine, 157, 875–881. Roberts, R., & Petretic-Jackson, P. (1998). Assessment measures for battered women. In: A. W. Burgess (Ed.), Advanced practice psychiatric nursing. Stamford, CT: Appleton & Lange. Strack, G., & McClane, G. (1999). How to improve your investigation and prosecution of strangulation cases. Austin, TX: National Center of Domestic and Sexual Violence. Retrieved March 12, 2008, from http://www.ncdsv.org/images/strangulation_article.pdf. The National Domestic Violence Hotline. (2008). National domestic violence hotline. Retrieved March 12, 2008, from http://www.ndvh.org. Tjaden, P., & Thoennes, N. (2000a). Extent, nature and consequences of intimate partner violence: findings from the National Violence Against Survey. Washington, DC: National Institute of Justice and the Centers for Disease Control and Prevention. Tjaden, P., & Thoennes, N. (2000b). Full report of the prevalence, incidence, and consequences of violence against women: Findings from the National Violence Against Women Survey. Washington, DC: National Institute of Justice and the Centers for Disease Control and Prevention. U.S. Department of Justice. (2007). Homicide trends in the United States. Retrieved March 12, 2008, from http://www.ojp.gov/bjs/ homicide/intimates.htm. Valente, S. (2002). Evaluating intimate partner violence. Journal of the American Academy of Nurse Practitioners, 14, 505–516.
Johnson, M., & Leone, J. (2005). The differential effects of intimate terrorism and situational couple violence. Journal of Family Issues, 26, 322–349. Kearney, M. (2001). Enduring love: A formal theory of women’s experience of domestic violence. Research in Nursing and Health, 24, 270–282.
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Varcarolis, E., Carson, V., & Shoemaker, N. (2006). Foundations of psychiatric mental health nursing: A clinical approach. St. Louis, MO: Saunders Elsevier. Yegadis, K. (1989). Women’s mental health in primary care. Philadelphia: W. B. Saunders. Zerbe, K. J. (1999). Trauma and violence. In: Women’s mental health in primary care. Philadelphia: W. B. Saunders.
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Mahoney, B. (2006). Reducing barriers against routine screening for intimate partner violence. American Journal for Nurse Practitioners, 10(10), 45–58.
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Get the Facts
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Post-Test Questions Instructions: To receive contact hours for this learning activity, please complete the online post-test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.
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1.
Coker et al. (2002) estimate that which percentages of women and men will experience IPV in their lifetimes? a. 11 percent of women and 12 percent of men b. 20 percent of women and 18 percent of men c. 29 percent of women and 22 percent of men
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Signs of IPV include: a. frequent rescheduling of health care visits b. overuse of health services c. the intimate partner driving the patient to health visits
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Documents recommended to be carried by victims of IPV include: a. car titles b. medical records c. mortgage papers or housing rental agreements Recommended approaches to screening for IPV include: a. reading non-verbal cues in order to decide if a woman should be screened for IPV b. using indirect terms to refer to abuse c. using screening tools to decide if a woman should be asked about IPV at all Safety strategies nurses can recommend to victims of IPV include: a. buying a new car b. changing jobs c. shopping and banking at different places Strangulation and choking describe two different actions. Which statement best describes this difference? a. Choking describes an assault that is intended to cause the victim harm, whereas strangulation describes a foreign object lodged in the victim’s throat. b. Strangulation describes an assault that is intended to cause the victim harm, whereas choking describes a foreign object lodged in the victim’s throat. c. Strangulation describes unintentional harm, whereas choking causes intentional harm. Safety recommendations for computer use for victims of IPV include: a. avoiding identity theft by using secure sites b. changing online passwords c. investing in anti-virus software
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Which of the following actions is an example of social abuse? a. forcing undesired pregnancy or rapidly repeated pregnancies b. making the victim account for money spent c. requiring the victim to ask permission before leaving the house
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For which race and gender groups (across all relationship categories) did the intimate homicide rate fall the most between 1976 and 2004? a. black females and males b. Hispanic females and males c. white females and males
10. IPV accounts for which percentage of homicides among pregnant women? a. 22 percent b. 31 percent c. 39 percent 11. Strategies of safety that the nurse may educate the victim to do when an argument is beginning may include: a. changing the subject matter of the argument b. encouraging the abuser to calm down c. moving out of a kitchen or bathroom 12. Which of the following race and gender groups have the highest prevalence of IPV? a. American Indian or Alaska Native women and men b. Asian women and men c. White women and men 13. IPV is an abusive relationship in which the perpetrator desires to have: a. a sense of importance to the victim b. financial security c. power and control over the victim 14. What is the estimated percentage of homeless women and children in the U.S. who are fleeing IPV? a. 25 percent b. 50 percent c. 75 percent 15. Which type of abuse is stalking? a. economic b. physical c. social
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