The scope of domestic violence includes violence against women, children, and elders. This course describes best practices for screening, assessment, and documenting signs of violence when seen in the healthcare setting. Outlines Kentucky reporting requirements and discusses state programs to reduce incidence.
The following information applies to occupational therapy professionals:
Criteria for Successful Completion
80% or higher on the post test, a completed evaluation form, and payment where required. No partial credit will be awarded.
Objectives: When you finish this course you will be able to:
Intimate partner violence (IPV) is defined as physical, sexual, or psychological harm by a current or former partner or spouse. It can occur among heterosexual or same-sex couples and does not require sexual intimacy. IPV is a serious, preventable public health problem that affects millions of people in the United States and throughout the world. In many societies this type of violence is considered “normal.” It varies in frequency and severity and occurs on a continuum, ranging from one hit that may or may not impact the victim to chronic, severe battering (CDC, 2010; WHO, 2013).
The terms domestic violence, family violence, wife beating, battering, spouse abuse, and dating violence are often used interchangeably. In an effort to facilitate the collection of data and make comparisons among jurisdictions, an effort is being made to use a consistent definition and the CDC advocates the definition of IPV given above (CDC, 2010).
Just as intimate partner violence can be thought of as a continuum, domestic violence may also encompass child abuse when children are physically and psychologically harmed when IPV occurs, and elder abuse when the perpetrator is an intimate partner.
Although women can be violent to men, the vast majority of intimate partner violence is perpetrated by men against women. From 1994 to 2010, U.S. Department of Justice statistics showed that IPV declined by more than 60% for both males and females, but they also show that 4 in 5 victims of IPV were female, and females ages 18 to 24 and 25 to 34 generally experienced the highest rates of IPV (Catalano, 2012).
The rate of fatal incidents of intimate partner violence—sometimes referred to as “intimate homicide”—fluctuated during the period from 1980 to 2008 in the United States. The percentage of males killed by an intimate dropped by 53%, but for females the percentage increased 5% during the same period. In 2008 the rate was 4.9% for males while it was 45% for females. The rate for both black and white males has remained about 5% since 2002, while for females it has risen from all-time lows in 1995 to 43% for black females and 45% for white females in 2008 (Cooper & Smith, 2011).
Describing trends based on law enforcement statistics can be problematic, however. In the United States, less than one-fifth of the women raped by an intimate partner reported their most recent rape to the police. In the National Violence Against Women Survey (NVAWS) done in 1996, most women and men who were physically assaulted failed to file a complaint, although women were more likely than men to report their victimization to the police (26.7% and 13.5%, respectively) (Tjaden & Thoennes, 2000).
This reluctance to report intimate partner violence to authorities is also a problem internationally. According to a World Health Organization (WHO) survey of more than 24,000 women in ten countries, over half of the physically abused women surveyed reported that they had never sought help from a health service, shelter, legal service, or anyone in any position of authority such as religious leaders, police, or other government organizations (WHO, 2005).
In 2006, when Kentucky’s governor appointed 36 members to the Council on Domestic Violence and Sexual Assault, the Cabinet for Health and Family Services noted in its press release that “a study of domestic violence in Kentucky reveals 1 of every 3 women has been victimized by an intimate partner” (KCHFS, 2006). The study, completed in 2005 by the IPV Surveillance Project, had helped to demonstrate that Kentucky women were indeed experiencing domestic violence at a higher rate than the national average (Fritsch, 2005).
In November 2009 a special report in the Louisville Courier-Journal stated that in the previous three years 49 Kentuckians had been “killed by their husbands, boyfriends, or former mates” (Wolfson, 2009). A recent editorial in the Maysville Ledger-Independent suggests that despite improvements, some things have not changed very much. Between October 2011 and September 2012, 25 Kentuckians lost their lives in acts of domestic violence, and one-third of Kentucky women report having been abused at least once. Kentucky is one of just a few states that does not allow dating partners to obtain protection orders, and it has one of the highest percentages of high school students subjected to dating violence (Ledger-Independent, 2013).
On September 12, 2012, all fifteen of Kentucky’s domestic violence programs participated in the 2012 National Census of Domestic Violence Services, a one-day survey held under the aegis of the National Network to End Domestic Violence. In just that one 24-hour period the state’s programs provided services to 1,107 victims of domestic violence and their children, including emergency shelter for 701 victims. Unfortunately, on that same day 84 requests could not be met due mostly to lack of funding; 69 of those requests were for shelter (NNEDV, 2012).
Kentucky’s Adult Protection Act (KRS 209) requires the reporting of known or suspected incidences of adult abuse, neglect, or exploitation, and all required reports of domestic violence incidents by law must be made to the Department for Community Based Services (DCBS), a department of the Kentucky Cabinet for Health and Family Services, Division of Protection and Permanency (KSP, 2012). [See later section of the course for specifics on Kentucky legislation.]
In fiscal year 2012 the DCBS investigated 19,337 allegations of domestic violence. This was a 2.1% decrease over 2011 (KSP, 2012). The number of allegations had begun to climb in 2008 and continued to climb through 2010, followed by small decreases in 2011 and 2012. However, the number of allegations investigated in 2012 was still greater than the 19,193 investigated in 2008.
Employment and economic stressors are known to play a role in domestic violence. The widespread economic problems in 2008–2010 may have exacerbated domestic violence in some situations and been one factor in the increased number of incidents (KSP, 2008–2012).
In fiscal year 2012 the Kentucky Domestic Violence Association (KDVA) received 24,560 domestic violence-related calls and 51,358 calls asking for information and/or referrals. Both figures represent sizable declines over 2011 (12% and 17% respectively), and in both cases a 31% decline over the highs measured in 2008 (KSP, 2008–2012). While these declines are important, they reflect only a return to pre-2008 numbers and domestic violence remains a critical problem in Kentucky.
The first spouse abuse shelter in Kentucky was opened by the Louisville YWCA in 1977, and by 1980 five more had opened. In 1981 staff members at those six shelter programs formed the Kentucky Domestic Violence Association (KDVA), which was intended to be a coalition of all the domestic violence programs in the state. “Its purpose was to provide mutual support, information, resource sharing and technical assistance; to coordinate services; and to collectively advocate for battered women and their children on statewide issues” (KDVA, 2009, n.d.-1).
Kentucky is divided into 15 multi-county Area Development Districts (ADDs) created by state law and run as local partnerships. The ADDs tap into local expertise and provide a means to organize planning, services, and statistical information across the state (BGADD, n.d.). Thus “it made sense to use [them] as targeted areas for domestic violence services.” KDVA reached its original goal of providing services in every district in 1985 (KDVA, 2009, n.d.-1). (In addition, there is a shelter program run by volunteers that serves just Pike County that can be reached here.
These 15 regional domestic violence programs began simply as safe shelters for domestic violence victims. This continues to be a critical part of the services provided, and these state-funded shelters have the capacity to shelter a total of 460 people at one time, down from 485 people in 2008. This is a miniscule number compared to the needs of victims for shelter and, in 2012, 2,475 people were unable to be sheltered at some time during the year, a significantly higher number than in 2011 and 2010 (KDVA, 2009, n.d.-2; KSP, 2010–2012).
Services Provided by Kentucky Domestic Violence Programs
New residential individuals served
New non-residential individuals served
These shelter programs now provide a variety of related support services, as over time staff members at these agencies have come to understand the complexity of the situation for victims of domestic violence and their growing needs. Among the variety of support services now provided to shelter residents and non-residents are:
In fiscal year 2012 KDVA member programs provided medical advocacy for 2,089 adult residential clients and 665 nonresidents, and legal advocacy for 2,537 adult residential clients and 16,148 nonresidents. Group and individual counseling sessions for all adult clients totaled nearly 99,000 hours (KDVA, 2012). These are just a few of the support services offered, and “the programs are also committed to preventing future domestic violence through public awareness and community education efforts. Domestic violence programs are working with schools, local professionals, and community groups to increase understanding of domestic violence issues” (KDVA, n.d.-2).
An important recourse for domestic violence victims is protective orders. Emergency Protective Orders (EPOs) and Domestic Violence Orders (DVOs) “are civil orders which are issued for the purpose of providing a victim of domestic violence with protection.” Usually the petitioner first asks for an EPO and the petition is reviewed by a judge. EPOs cannot be effective for more than 14 days, so if the judge grants the order a hearing date is set within that time period and the respondent must be served with a copy of the order. At the hearing, the court will decide if a DVO should be issued. A DVO can be effective for up to three years. “Both [EPOs and DVOs] are valid orders of protection and can be immediately enforced by the police and the courts” (Legal Aid Society, 2009; KRS 403.740). A study released in 2009 demonstrated that protective orders in Kentucky have generally been effective at ending or reducing violence and reducing fear. However, they have not proven to be as effective for victims of stalking (Logan et al., 2009; Wolfson, 2009).
According to statistics compiled by the Kentucky State Police (KSP) for its annual Crime in Kentucky report, 21,207 petitions were filed by persons seeking DVOsin FY 2012. This represents a small decline over 2011, but both figures were higher than the 19,250 filed in 2010. (In 2008 and 2009 the total petitions each year were in excess of 26,000.) Emergency Temporary Orders and Emergency Protective Orders reported to the Law Information Network of Kentucky (LINK) showed an 11% decrease in 2012 over 2011 (KSP, 2012).
In Kentucky batterer intervention is established by statute (KRS 403.7505) and administrative regulation (920 KAR 2:020). A certification program for batterer intervention providers was established in 1996 and the first providers were certified two years later. There are now about 121 of these certified mental health professionals offering services in 54 counties. A list of providers is available from the DCBS website (KCHFS, 2013).
According to Kentucky law (KRS 403.720), “domestic violence and abuse” means:
. . .physical injury, serious physical injury, sexual abuse, assault, or the infliction of fear of imminent physical injury, serious physical injury, sexual abuse, or assault between family members or members of an unmarried couple.
“Family member” means a spouse, including a former spouse, a grandparent, a parent, a child, a stepchild, or any other person living in the same household as the child if the child is the alleged victim.
“Member of an unmarried couple” means each member of an unmarried couple which allegedly has a child in common, any children of that couple, or a member of an unmarried couple who are living together or have formerly lived together.
The Centers for Disease Control and Prevention (CDC) describes four types of intimate partner violence—physical violence, sexual violence, threats of physical or sexual violence, and psychological/emotional violence. Stalking and cyberstalking are increasingly being included as another type of intimate violence.
Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm (CDC, 2010). Physical violence includes, but is not limited to:
Physical violence also includes coercing other people to commit any of the above acts (CDC, 2010).
Research has shown that physical violence is often accompanied by psychological abuse and in one-third to one-half of cases, by sexual abuse (Heise & Garcia-Moreno, 2002). The violence is usually not limited to one instance. The National Violence Against Women Survey (NVAWS) found that women who were physically assaulted by an intimate partner averaged 6.9 physical assaults by the same partner, while men who were assaulted averaged 4.4 assaults.
Women experience more chronic and injurious physical assaults at the hands of intimate partners than do men. The NVAWS found that more than 40% of women who were physically assaulted by an intimate partner were injured during their most recent assault, compared with about 20% of the men. Most injuries, such as scratches, bruises, and welts, were minor. More severe physical injuries may occur depending on severity and frequency of abuse. Physical violence can lead to death.(Tjaden & Thoennes, 2000).
In 2007 in the United States, 700 males and 1640 females were murdered by an intimate partner (Catalano, 2009).
A sexual act is defined as contact between the penis and the vulva or the penis and the anus involving penetration, however slight; contact between the mouth and the penis, vulva, or anus; or penetration of the anal or genital opening of another person by a hand, finger, or other object (Saltzman, 2001).
Abusive sexual contact is intentional touching directly, or through the clothing, of the genitalia, anus, groin, breast, inner thigh, or buttocks of any person against his or her will, or of any person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to be touched (Saltzman, 2001).
Sexual violence involves:
Sexual and physical abuse is often accompanied by controlling behaviors. In a World Health Organization survey of more than 24,000 women in ten countries, the percentage of those who had experienced one or more of the following controlling behaviors ranged from 20% in Japan to 90% in urban United Republic of Tanzania:
Threat of physical or sexual violence is defined as the use of words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm. This includes the use of words, gestures, or weapons to communicate the intent to compel a person to engage in sex acts or abusive sexual contact when the person is either unwilling or unable to consent. A person threatening physical or sexual violence may use words such as:
Or actions such as:
Psychological/emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. It is considered psychological/emotional violence when there has been prior physical or sexual violence or prior threat of physical or sexual violence. Psychological and emotional abuse involves trauma to the victim caused by acts, threats of acts, or coercive tactics (CDC, 2010).
Psychological/emotional abuse can include:
Coercive control and intimidation by the abusive partner is considered an underlying component of all of these types of violence. The abusive partner’s ability to control relies on the abused person’s belief that if she or he does not comply with the abusive partner’s demands, the victim, the victim’s children, or other persons or things the victim cares about will be harmed. Often, threats are alternated with acts of kindness from the perpetrator, making it difficult for the victim to break free of the cycle of violence.
The ten-country World Health Organization survey and other research has consistently shown that emotional abuse can have a more profound and negative effect than physical violence. Between 20% and 75% of women across all the countries surveyed reported being the recipient of emotional abuse within the previous 12 months (WHO, 2005).
In addition to the four types of intimate partner violence described above, stalking and cyberstalking have become increasingly common. Stalking generally refers to “harassing or threatening behavior that an individual engages in repeatedly, such as following a person, appearing at a person’s home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing a person’s property” (CDC, 2010).
According to the National Violence Against Women Survey, stalking by intimates is more prevalent than previously thought. Almost 5% of surveyed women and 0.6% of surveyed men reported being stalked by a current or former spouse, cohabiting partner, or date at some time in their lifetime; 0.5% of surveyed women and 0.2% of surveyed men reported being stalked by such a partner in the previous 12 months (Tjaden & Thoennes, 2000).
According to these estimates, more than 500,000 women and 185,000 men are stalked by an intimate partner annually in the United States. These estimates exceed previous estimates of stalking prevalence in the general population. The findings suggest that intimate partner stalking is a serious criminal justice problem, and each state should develop constitutionally sound and effective anti-stalking statutes and intervention strategies (Tjaden & Thoennes, 2000).
Today, stalkers have at their fingertips a wide array of computers and equipment including the Internet, global positioning systems, cell phones, and tiny digital cameras. In many states, general stalking statues have not kept up with these new technologies. However, changes in the law in 2009 made cyberstalking a crime in Kentucky (KRS 508.130–150). Additional information for identifying and dealing with cyberstalking is available from the Kentucky Attorney General’s office and here.
Violence against women has been the focus of international attention for more than twenty years. In 1993 the World Conference on Human Rights published the Declaration on the Elimination of Violence Against Women. It established that, according to international human rights law, “states have a duty to exercise due diligence to prevent, prosecute, and punish violence against women” (WHO, 2005).
Recognizing the need for research in the area of intimate partner violence, in 2005 the World Health Organization (WHO) completed a ten-country population-based survey of 24,000 women called the WHO Multi-country Study on Women’s Health and Domestic Violence against Women. The WHO researchers asked participants a series of questions about physical and sexual violence, emotional abuse, and controlling behaviors.
Overall, the proportion of women who had ever suffered physical violence by a male partner ranged from 13% in Japan to 61% in provincial Peru. Japan had the lowest level of sexual violence at 6%, while Ethiopia had the highest figure of 59%. The majority of settings were between 10% and 50% (WHO, 2005).
It is well known that violence perpetrated against women by an intimate partner is often accompanied by emotionally abusive and controlling behavior. The National Violence Against Women survey found that women whose partners were jealous, controlling, or verbally abusive were significantly more likely to report being raped, physically assaulted, or stalked by their partners, even when other socio-demographic and relationship characteristics were controlled.
Having a verbally abusive partner was the variable most likely to predict that a woman would be victimized by an intimate partner. These findings support the theory that violence perpetrated against women by an intimate partner is often part of a systematic pattern of dominance and control (Tjaden & Thoennes, 2000).
Violence against women incorporates intimate partner violence, sexual violence, and other forms of violence against women such as physical violence committed by acquaintances or strangers (Saltzman, 2001). The victims are often emotionally involved and economically dependent upon the person victimizing them. In contrast, men are more likely to be victimized by someone outside their close circle of relationships (Heise & Garcia-Moreno, 2002).
Depending on the population, setting, or frequency of asking, between 0.9% and 20.1% of women in the United States reported they have experienced violence during pregnancy. Violence during pregnancy may be more common than some conditions for which pregnant women are routinely screened. As with screening for gestational diabetes, neural tube defects, preeclampsia, and behavioral risk factors such as smoking and alcohol use, screening for intimate partner violence should be incorporated into routine prenatal care (CDC, 2006).
Women who report violence around the time of pregnancy have reported higher prevalence of other demographic and psychosocial risk factors that also may have an effect on pregnancy. These include:
Intimate partner violence is often associated with the abuse of children. This is an important public health issue because witnessing violence in the home as a child is a strong risk factor for involvement in abusive relationships as an adult. In addition, experiencing abuse as a child has been associated with other risk factors such as depression, substance abuse, poor school performance, and high-risk sexual activity (CDC, 2012a).
The federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as, at minimum:
This definition of child abuse and neglect refers specifically to parents and other caregivers. A child under this definition generally means a person who is under the age of 18 or who is not an emancipated minor (Child Welfare Information Gateway, 2013, 2010).
CAPTA provides definitions for sexual abuse and the special cases related to withholding or failing to provide medically indicated treatment but does not provide specific definitions for other types of maltreatment such as physical abuse, neglect, or emotional abuse. While federal legislation sets minimum standards, each state is responsible for providing its own definition of maltreatment within civil and criminal contexts (Child Welfare Information Gateway, 2013, 2010).
In Kentucky, abused or neglected child means a child whose health or welfare is harmed or threatened with harm when his or her parent, guardian, or other person exercising custodial control or supervision:
Physical injury means substantial physical pain or any impairment of physical condition.
Serious physical injury means physical injury that creates a substantial risk of death, or causes serious and prolonged disfigurement, prolonged impairment of health, or prolonged loss or impairment of the function of any bodily member or organ (Child Welfare Information Gateway, 2009).
Children exposed to domestic violence may be the victims of co-occurring maltreatment. In particular, domestic violence is a significant risk factor for verbal abuse, physical punishment, and physical abuse of children. Although high rates of co-occurring domestic violence and child maltreatment have been noted in the general population, this co-occurrence has most commonly been investigated in clinical samples of abused women and of physically abused children, with the majority of studies indicating rates of co-occurrence ranging from 30% to 60% (Kelleher, 2006).
There is evidence that children who are exposed to domestic violence and also experience maltreatment are at risk for poor development. There also is a growing concern that children’s exposure to domestic violence constitutes a type of psychological or emotional abuse in and of itself (Kelleher, 2006).
Although domestic violence and child maltreatment commonly occur together, policy makers and planners of services lack a nationally representative study that examines the prevalence of this co-occurrence. Equally as important is the need for information on state and local policies and practices around services for families with co-occurring domestic violence and child maltreatment (Kelleher, 2006).
Domestic violence is a significant problem for 30% to 40% of families in the child welfare system. Because co-occurring domestic violence and child maltreatment are so prevalent, many communities have implemented policies and practices to protect women and children from domestic violence, and to provide services, especially as they relate to interactions with the child welfare system. Many of these initiatives have arisen out of local advocacy through domestic violence centers and services, while others come from national movements promulgated by the National Council of Juvenile and Family Court Judges, such as its Model Code or its more recent policy and practice recommendations, sometimes referred to as the “Greenbook” (Kelleher, 2006).
In 1980 the Kentucky Legislature passed legislation designed to protect adults who were “unable to manage their own affairs or to protect themselves from abuse, neglect, or exploitation” (KRS 209.090). For the purposes of this law the following definitions apply:
According to the best available estimates, between 1 and 2 million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection (NCEA, 2005). Complicating these estimates, however, is the difficulty in defining and quantifying elder abuse. Available data indicate that the highest rates of elder abuse are among women and those aged 80 and older. In 90% of cases, the perpetrator is a family member, most often a spouse or adult child (Nelson, 2004).
A combination of individual, relational, community, and societal factors contribute to the risk of becoming either a victim or a perpetrator of intimate violence. Risk factors are contributing factors and may or may not be direct causes. Not everyone who is identified as “at risk” becomes involved in violence.
When considering victims and perpetrators, some risk factors are the same and some are associated with one another. For example, childhood physical or sexual victimization is a risk factor for both future perpetration and victimization. Understanding these multilevel factors can help identify various opportunities for prevention.
The termination of a relationship poses an increased risk for, or escalation of, intimate partner violence. This assumption is based on two types of evidence: divorced or separated women report more intimate partner violence than do married women. Also, interviews with men who have killed their wives indicate that either threats of separation by their partner or actual separation are most often the precipitating events that lead to the murder (Tjaden & Thoennes, 2000).
The National Violence Against Women Survey found that married women who lived apart from their husbands were nearly 4 times more likely to report that their husbands had raped, physically assaulted, and/or stalked them than were women who lived with their husbands (20% versus 5.4%). Similarly, married men who lived apart from their wives were nearly 3 times more likely to report that their wives had victimized them than were men who lived with their wives (7.0% and 2.4%) (Tjaden & Thoennes, 2000).
These findings suggest that termination of a relationship poses an increased risk of intimate partner violence for both women and men. However, it should be noted that the survey data do not indicate whether the violence happened before, after, or at the time the couple separated. Thus, it is unclear whether the separation triggered the violence or the violence triggered the separation (Tjaden & Thoennes, 2000).
Factors Associated with a Man’s Risk for Abusing His Partner
Traditional gender norms
The World Health Organization population survey investigated which factors might protect a woman from intimate partner violence and which factors put her at greater risk. As in other studies, this survey looked at individual and partner factors as well as factors related to the woman’s immediate social context (WHO, 2005).
The survey found that in all but two settings (Japan and Ethiopia), younger women (aged 15 to 19 years) were at higher risk for physical or sexual abuse within the last 12 months. In all but two settings (Bangladesh and Ethiopia), women who had been separated or divorced reported much more partner violence during their lifetime than currently married women. Higher education was associated with less violence in many settings (WHO, 2005).
Rural living may present additional problems for victims of domestic violence, as well as for healthcare providers practicing in rural settings. Unfortunately, research on the specific problems of domestic violence in rural areas is still only a small portion of the work done on domestic violence overall.
Available research suggests some important differences between domestic violence in rural and urban areas and highlights details that merit further research. While the rates of domestic violence in rural and urban areas appear to be similar, victim experiences may be very different. For rural victims of domestic violence, levels of education, employment opportunities, and income are all usually lower. More are homeless, and economic and social support options are generally fewer. Rural victims also appear to experience abuse earlier in their relationships than do urban women (Logan et al., 2003). While protective orders appear to be equally effective in rural and urban areas, rural victims encounter more problems obtaining the orders and getting them enforced, and they experience more personal distress and fear than do their urban counterparts (Logan et al., 2009).
In 2005 a study of twenty years of FBI statistics demonstrated that the more rural the area (based on size of population and distance from a major urban area) the more likely a murdered person was to have been murdered by a family member or intimate partner. Analysis of the data from 1980–1999 showed that overall “rates for family and intimate partner murders declined regardless of place, whereas rates of intimate partner murders increased only with rurality” (Gallup-Black, 2005).
As noted earlier, isolation—emotional, physical, and economic—can be a factor in why some victims stay in abusive relationships; the geographical circumstances of rural living can exacerbate this factor. There are numerous behaviors employed by abusers to create isolation for their victims, such as limiting a victim’s access to family vehicles or preventing her from obtaining a driver’s license, ridiculing her in front of others, or accusing her of flirting—thus making her even less likely to invite others to the home or go out herself, and even removing the telephone when leaving the house so that she has no means to communicate with others.
For rural victims these abuser behaviors may be compounded by the realities of rural living, including:
Not only is access to routine health care often limited in rural areas, but rural citizens tend to have fewer insurance resources, providers may be unprepared to do routine IPV screening, and tight-knit communities may discourage people from reporting abuse. Locating shelters in rural areas is also more difficult because they are harder to hide.
Rural healthcare providers not only need to be able to identify domestic violence victims but also to be prepared to offer assistance that addresses the particular needs and problems of rural women. Patients experiencing abuse may have complaints or injuries that include arthritis, irritable bowel syndrome, stomach ulcers, chronic pain, migraines, and eating disorders, and one study found that approximately 64% of rural women with an STD are involved in an abusive physical and sexual relationship. Other closely associated complaints include insomnia, depression, post traumatic stress disorder, panic disorder, and substance abuse (Clifford, 2003). In addition, safety plans and escape options for rural women may need to be adjusted to meet the specific realities of their situations.
In 2003 dollars, costs associated with intimate partner violence exceeded $8.3 billion, which included $460 million for rape, $6.2 billion for physical assault, $461 million for stalking, and $1.2 billion in the value of lost lives. Victims of severe intimate partner violence lose nearly 8 million days of paid work—the equivalent of more than 32,000 full-time jobs—and almost 5.6 million days of household productivity each year (CDC, 2012a, 2003). This is generally considered an underestimate because the costs associated with the criminal justice system were not included.
The U.S. medical community treats millions of intimate partner rapes and physical assaults annually. Of the nearly 5 million intimate partner rapes and physical assaults perpetrated against women annually, approximately 2 million will result in an injury to the victim, and more than half a million will result in some type of medical treatment to the victim (Tjaden & Thoennes, 2000).
Of the estimated 2.9 million intimate partner physical assaults perpetrated against men annually, 581,391 will result in an injury to the victim, and 124,999 will result in some type of medical treatment to the victim. Many medically treated victims receive multiple forms of care—ambulance services, emergency room care, or physical therapy—and multiple treatments, such as several days in the hospital, for the same victimization (Tjaden & Thoennes, 2000).
In general, victims of repeated violence experience more serious consequences than victims of one-time incidents. Women with a history of intimate partner violence are more likely to display behaviors that lead to further health risks such as substance abuse, alcoholism, and suicide attempts. Intimate partner violence is also associated with a variety of negative health behaviors; studies show that the more severe the violence, the stronger its relationship to negative health behaviors by victims.
Some victims may engage in high-risk sexual behaviors such as unprotected sex, decreased condom use, early sexual initiation, choosing unhealthy or multiple sexual partners, or trading sex for food, money, or other items. There is often an increased use of harmful substances and illicit drug use, alcohol abuse, and driving while intoxicated. Victims of intimate partner violence may also engage in unhealthy diet-related behaviors such as smoking, fasting, vomiting, overeating, and abuse of diet pills. They may also overuse health services.
Women who experience severe aggression by men, such as not being allowed to go to work or school or having their lives or their children’s lives threatened, are more likely to have been unemployed in the past and be receiving public assistance (CDC, 2012a, 2003). They may have restricted access to services, strained relationships with healthcare providers and employers, and be isolated from social networks.
Psychological Consequences of Intimate Partner Violence
The number of medical personnel treating injuries annually is in the millions. To better meet the needs of IPV victims, medical professionals should receive training in screening and assessment, learn to recognize the physical consequences of intimate partner violence, and initiate appropriate medical intervention strategies.
Clinicians have an opportunity to identify and intervene on behalf of abused women and men and to assist in breaking the intergenerational cycle that could affect their children. Whenever possible, at the point of detection clinicians should communicate with the family’s other healthcare providers, such as pediatricians. Clinicians should also be aware of and follow state reporting requirements related to domestic violence or child abuse and neglect (CDC, 2006).
Training in the use of efficient assessment methods can increase the percentage of providers that screen for intimate partner violence. When providers are asked why they do not screen for violence, they commonly indicate four major barriers:
Health care organizations and individual providers can increase competency in and commitment to screening for violence. One such screening and intervention method can be summarized in the acronym RADAR, which was developed by the Massachusetts Medical Society (CDC, 2006).
Use Your RADAR:
The first step in the RADAR process is to routinely screen for violence. Assume that all patients are at risk for violence and ask every patient as part of his or her routine health assessment. Screening requires that the provider ask directly for information at multiple visits. In cases where violence is identified, document your findings in the patient’s chart. Assess your patient’s safety—is the patient or are his or her children in immediate danger? Finally, review the patient’s options and provide him or her with referrals (CDC, 2006).
A woman’s behavior during office visits can provide warning signs for possible intimate partner violence. Abused women may present with a flat affect or as frightened, depressed, or anxious. Severe cases may be characterized by symptoms of post traumatic stress disorder (PTSD), such as dissociation, psychic numbing, or startle responses to touch. Abused women may appear overly compliant. Most patients have a number of questions, but an abused woman may have “learned” not to question authority. Conversely, an abused woman may exhibit excessive distrust of healthcare providers, possibly because of the fear and shame associated with the abuse and the possibility of its detection (CDC, 2006).
Possible Signs of IPV in Women
Source: (CDC, 2006).
Medical records are often used as evidence in domestic violence cases. Clear, concise, and factual documentation can help establish that abuse has occurred. Medical professionals may not be aware that subtle differences in the way they document cases of domestic abuse can affect the usefulness of their records if there is a hearing. For example, “excited utterances” or “spontaneous exclamations” should be carefully documented because they have exceptional credibility due to their proximity to the event and because they are not likely to be premeditated. The victim or the victim’s attorney can use a medical record to obtain a restraining order, qualify for special status or exemptions in public housing, welfare, health and life insurance, victim compensation, and immigration relief related to domestic violence and in resolving landlord-tenant disputes (Isaac & Enos, 2001).
According to a number of studies, many medical records are not sufficiently well-documented to provide adequate legal evidence of domestic violence. A study of 184 visits for medical care in which an injury or other evidence of abuse was noted revealed major shortcomings in the records:
Medical records could be more useful to domestic violence victims in legal proceedings if some minor changes were made in documentation. Clinicians can do the following:
Kentucky’s Adult Protection Act (KRS 209), passed in 1976, requires the reporting of known or suspected incidences of adult abuse, neglect, or exploitation, and it was expanded in 1978 to include mandatory reporting and provision of voluntary protective services to spousal abuse victims. Changes in 2005 specifically addressed protection for victims of domestic violence with KRS 209A.
In 1996 legislation was enacted that mandated training about domestic violence for nurses and some other healthcare professionals (KBN, 2013).
An important recourse for domestic violence victims is protective orders, and KRS 403 deals with the purpose of, types, and procedures for obtaining protective orders. These are intended “to allow persons who are victims of domestic violence and abuse to obtain effective, short-term protection against further violence and abuse in order that their lives will be as secure and as uninterrupted as possible” and to make it easier for law enforcement officers to respond to domestic violence and abuse incidents and to give them authority to immediately apprehend violators (KRS 403.715(1)). “Any family member or member of an unmarried couple who is a resident of this state or has fled to this state to escape domestic violence and abuse” may file a petition for a protective order (KRS 403.725(1)).
In many states, general stalking statutes have not kept up with new electronic technologies. However, in 2009 cyberstalking was made a crime in Kentucky by the addition of “computers, the Internet or other electronic” devices to the definitions within the law prohibiting stalking (KRS 508.130–150).
Legislation in 2010 brought a noteworthy expansion of enforcement options against perpetrators of domestic violence when it included, among other things, the ability for “judges to order those who violate a domestic violence order to wear a global positioning system (GPS) tracking device. . . [and] extend[ed] the continuance of an un-served emergency protective order for 6 months, rather than the current 90 days” (WFIE, 2010).
Since then, legislation to extend the right to obtain protective orders to dating partners has been proposed in each legislative session, but has not passed. The legislation is expected to be proposed again in the 2014 legislature (Autry, 2013).
All suspected cases of domestic violence (including child, elder/adult, and spouse abuse) are to be reported to the Cabinet for Health and Family Services (CHFS). During normal working hours local Protective Services should be contacted, but at all other times call 1-877-597-2331 for child abuse and 1-800-752-6200 for adult abuse. (See Resources at the end of the course for additional numbers and contact information.)
“If you believe a child is being abused, neglected or is dependent, you should call the Child Protection Hot Line at 1-877-KYSAFE1 (1-877-597-2331) or the Protection and Permanency office in your county” (KCHFS, 2013a). A list of contact information for those offices is available here.
Did you know. . .
If you suspect elder abuse, you are legally required to report it (CHFS, 2013b).
The DCBS offers this guidance for anyone who is concerned about possible elder abuse:
If you believe that an elderly person is in imminent danger, call 800-752-6200 or your local law enforcement agency immediately. If the person is not in imminent danger but you are suspicious, watch the way the caregiver acts toward the elderly or disabled person. Look for a pattern of threatening, harassing, blaming or making demeaning remarks to the person—or isolating the person from family members and friends. Watch for an obvious lack of helpfulness or indifference, aggression or anger toward the person. Listen for conflicting stories about the elderly or disabled person’s illnesses or injuries.” Know the signs of neglect, physical abuse, sexual abuse, emotional/psychological abuse, and financial abuse. (CHFS, 2007)
A detailed list of many of the signs of self-neglect, caregiver neglect, physical abuse, emotional abuse, and financial abuse are provided on the CHFS Elder Abuse Awareness website here.
Kentucky Revised Statue 209A.030 states the following:
In January 1996 the Kentucky Attorney General rendered a written interpretation of the law at the request of a physician. This document known as Ky. OAG 96-6 may also be of help to nurses wishing clarification of the law. The full text may be found on the attorney general’s website by searching “opinion 96-6.”
Most of the efforts directed against intimate personal violence center on reducing future additional risk, dealing with the consequences of the violence for the victim, and processing the perpetrators through the judicial system. As with its first agenda in 2002, the National Center for Injury Prevention and Control’s new agenda for 2009–2018 reiterates the goal for prevention and education: stopping intimate personal violence from happening in the first place (primary prevention). Research efforts are urgently needed surrounding “early risk and protective factors related to perpetration.” A better understanding of these factors should lead to more effective prevention programs. As before, prevention must address individual, relationship, community, and societal factors (NCIPC, 2009).
The National Center for Injury Prevention and Control has identified two tiers of research priorities for the next ten years aimed at preventing sexual violence and intimate partner violence. These ambitious goals reflect the strong need for detailed and broad-based data for the formulation and implementation of prevention strategies for sexual violence and intimate partner violence.
Tier 1 includes:
Tier 2 includes:
The World Health Organization, following its ten-country survey of violence against women made the following recommendations for prevention and education:
Kentucky Reporting Help Lines
Child Protection Hot Line
877-KYSAFE1 or 877 597 2331
Adult Abuse Reporting Hotline
800 752 6200
VINE: The National Victim Notification Network / VINELink
Victim Information and Notification Everyday
800 511 1670
Kentucky Domestic Violence Association
111 Darby Shire Circle
Frankfort, KY 40601
Phone: 502 209-KDVA (5382)
Fax: 502 226-KDVA (5382)
Email: email@example.com (general information)
http://kdva.org/victim_services/kydvcenter.html (lists contact info for regional assistance programs)
National Domestic Violence Hotline
(Linea Nacional sobre la Violencia Domestica)
800 799-SAFE (800 799 7233)
TDD: 800 787 3224
Centers for Disease Control and Prevention
Violence Prevention: Intimate Partner Violence
Rural Assistance Center
The National Women’s Health Information Center
Violence Against Women
For a presentation of domestic abuse that includes videos depicting the survivors, see
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