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Florida: Domestic Violence Update

Nancy Evans, BS

This course meets the domestic violence continuing education requirement for healthcare providers in the state of Florida. Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing.

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here.

SCOPE OF DOMESTIC VIOLENCE

Domestic violence is the use of physical abuse, verbal or emotional abuse, sexual abuse, or economic abuse (eg, withholding money, lying about assets) to exert power or control over someone or to prevent someone from making a free choice. Domestic violence is a crime in all fifty states. Three-fourths of domestic violence victims are women. Domestic violence is a major public health problem in the United States and around the world.

A landmark international study of 24,000 women in ten countries found that 1 in 6 women has experienced domestic violence, yet the problem remains mostly hidden. Women who experience domestic violence have more than double the risk of poor health, and physical and mental health problems, than women not abused (WHO, 2005). According to Lee Jong-Wook, director-general of the World Health Organization (WHO), "This study shows that women are more at risk from violence at home than in the street."

The Centers for Disease Control and Prevention (CDC) report that domestic violence affects more than 32 million Americans annually, causing more than 2 million injuries and approximately 1,300 deaths (CDC, 2005). Domestic violence strikes all ages, cultural/ethnic/religious groups, and social classes. Rape, incest, and dating violence are all considered to be forms of domestic violence.

A 2006 report from the U.S. Department of Justice indicates that the rate of domestic violence declined by 50% between 1990 and 2003. Between 2003 and 2004, however, the rate of nonfatal domestic violence for black females and for white males nearly doubled.

The National Domestic Violence Hotline (NDVH) reported that the demand for family violence services increased by 15 percent between May 31, 2004 and May 31, 2005. The NDVH has seen a 134 percent increase in the number of calls answered since the hotline was created in 1996 (NDVH, 2005). It is impossible to know the actual incidence and prevalence of domestic violence because many of these crimes are not reported to anyone. Feelings of shame, fear, and hopelessness prevent victims from seeking protection and support.

The truth is, domestic violence is rampant and diverse, and it's still something no one wants to talk about. Sheryl Cates, Executive Director National Domestic Violence Hotline

Victims of domestic violence are usually women and children. Perpetrators of domestic violence are generally, though not always, men. According to the U.S. Department of Justice (2005), 73 percent of domestic violence victims are women and 76 percent of perpetrators are men. Children who witness domestic violence may become victims themselves. One study showed that children of abused mothers were 57 times more likely to have been physically injured because of violence between their parents than children of nonabused mothers (Parkinson et al., 2001).

Because the term domestic violence tends to overlook male victims as well as violence between same-sex partners, the CDC prefers the more specific term intimate partner violence (IPV). Some agencies prefer the term domestic abuse because it makes visible the nonphysical components of an abusive situation; these include psychological or emotional abuse, threatening, and stalking, as well as neglect or financial exploitation, particularly of older people. Family violence is also used to describe abusive domestic situations because children are often involved.

Saltzman and colleagues (2002) identified four types of IPV:

• Physical violence
• Sexual violence
• Threats of physical or sexual violence
• Psychological/emotional violence

They define physical violence as "the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one's body, size, or strength against another person."

Sexual violence has three categories: "(1) use of physical force to compel a person to engage in a sexual act against his or her will, even if the act is not completed; (2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and (3) abusive sexual contact."

Threats of physical or sexual violence include the use of "words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm."

Psychological/emotional violence "involves trauma to the victim caused by acts, threats of acts, or coercive tactics." Psychological/emotional abuse can include, but is not limited to humiliation, controlling what the victim can and cannot do, withholding information, deliberately embarrassing the victim, isolating the victim from family and friends, and denying access to money or other basic resources.

Stalking is considered by some states (including Florida) as a type of IPV. Stalking generally refers to repeated behavior, such as following someone, that evokes a high level of fear in the victim (Tjaden & Thoennes, 2000).

Florida law (s.784.048) defines stalking as willfully, maliciously, and repeatedly following, harassing, or cyberstalking another person, which is "a misdemeanor of the first degree, punishable as provided in s.775.082 or s.775.083." Florida law defines cyberstalking as engaging in "a course of conduct to communicate, or to cause to be communicated, words, images, or language by or through the use of electronic mail or electronic communication, directed at a specific person, causing substantial emotional distress to that person and serving no legitimate purpose."

If the stalker makes "a credible threat with the intent to place that person [the one being stalked] in reasonable fear of death or bodily injury of the person or the person's child, sibling, spouse, parent, or dependent," the offense becomes "aggravated stalking, a felony of the third degree, punishable as provided in s.775.082, s., 775.083, or s.775.084."

The National Center for Victims of Crime (NCVC, 2003) defines cyberstalking as "threatening behavior or unwanted advances directed at another using the Internet and other forms of online and computer communications."

Cyberstalking has become an all-too-common means of harassment, particularly by spurned intimate partners. For example, one Florida woman reported to the Tampa police that a man she had dated for eight weeks called her 600 times in two days after their breakup. In addition, he sent her more than 100 emails in one month (Kalfrin, 2007). As with other forms of IPV, victims often fail to report cyberstalking.

Even though cyberstalking does not involve physical contact with the perpetrator, it can constitute emotional and psychological abuse. NCVC recommends that victims send the stalker one clear written warning stating that the contact is unwanted and to cease sending any communications. If the harassment continues, victims should file a complaint with the perpetrator's internet service provider (ISP) as well as with their own ISP. Victims should keep copies of all written communications and a log of phone calls. Filing a report with local law enforcement requesting a protective injunction puts the crime on record in the event that legal prosecution becomes necessary.

Intimate partner violence is one of the most common and least reported crimes. According to the National Violence Against Women Survey (National Institute of Justice, 2000):

• Approximately 1.5 million women and more than 800,000 men are raped and/or physically assaulted by an intimate partner annually.
• About 25 percent of women and 8 percent of men reported being raped and/or physically assaulted by a current or former spouse, cohabiting partner, or date at some time in their life.
• Thirty-nine percent of female victims of violence reported being injured. An estimated 500,000 female victims use medical services as a result of violence-related injuries. Sixty-two percent of these women were seen in emergency rooms.

The risk of becoming a victim of IPV is highest among American Indian and Alaskan Native women and men, African American women, Hispanic women, young women, women who are separated or divorced, and women below the poverty line (Bureau of Justice, 2006). Other risk factors include alcohol and drug use, high-risk sexual behavior, having witnessed or experienced violence as a child, being poorly educated, and unemployment. Women whose male partner is verbally abusive, jealous, or possessive are at high risk for IPV, as are those women who have more education than their partner. Couples with disparities in income, education, or job status are also at higher risk for IPV (Crandall et al., 2004).

Congress enacted the Violence Against Women Act (VAWA) in 1994 to expand efforts to raise awareness of domestic violence and increase the number of shelters and other resources for battered women. In December 2005, Congress reauthorized the VAWA programs as part of the Victims of Trafficking and Violence Prevention Act of 2000 (NOW, 2005). Additional information about the federal programs funded by VAWA can be found on the Department of Health and Human Services website: http://www.hhs.gov.

Injuries sustained during episodes of violence are only part of the damage to victims' health. Physical and psychological abuse are related to other adverse effects, including back pain, pelvic pain, gynecological disorders, gastrointestinal disorders, problem pregnancies, sexually transmitted diseases (STDs), headaches, central nervous system disorders, and heart or circulatory conditions (Coker et al., 2002; Campbell et al., 2002; Heise & Garcia-Moreno, 2002; Plichta, 2004; Tjaden & Thoennes, 2000).

Intimate partner violence is also linked to mental health problems, including depression, anxiety, antisocial behavior, low self-esteem, inability to trust men, fear of intimacy, and post-traumatic stress disorder (Heise & Garcia-Moreno, 2002; Roberts, Klein, & Fisher, 2003). Women who have experienced IPV also have an increased risk of substance abuse and suicide (SOGC, 2005).

On average, more than three women are murdered by their intimate partners each day in the United States. According to U.S. Bureau of Justice (2006), nearly one-third of female homicides are committed by intimate partners.

Research indicates that as many as 10 million American children witness IPV within their families each year (Carlson, 2000). These children report numerous fears about their mothers, including fear of serious harm to her and to themselves, as well as fear of abandonment. Living with intense anger and unpredictable behaviors creates a chronic and corrosive anxiety state. Child victims of violence, particularly boys, often grow up to become batterers themselves.

Women aged 20 to 34 have the highest per capita rate of nonfatal IPV (Bureau of Justice, 2007). Twenty-five percent of female high school students in Massachusetts reported experiencing physical or sexual abuse by a dating partner (Silverman et al., 2001). In the 2003 national Youth Risk Behavior Surveillance report, nearly 9 percent of students in grades 9 to 12 reported having been hit, slapped, or purposely hurt physically by a boyfriend or girlfriend during the twelve months preceding the survey. Dating violence was more prevalent among African American students than among white or Hispanic students. Nearly 12 percent of female students reported ever having been physically forced to have sex against their will (Grunbaum et al., 2004).

Elder abuse has been described as a national disgrace…. Elder abuse is also a disgrace to families. That's because elders are most often abused in their own homes. Carolyn S. Wilken, PhD

Many older Americans, particularly women, also experience domestic violence. According to the American Psychological Association (2007), each year an estimated 2.1 million older Americans experience physical, psychological, or other forms of abuse, neglect, or exploitation. These statistics show only a small corner of a horrific picture, however; experts estimate that there are five unreported cases of abuse and neglect for every one reported.

Reports to Adult Protective Services (APS) agencies of domestic elder abuse increased 150 percent between 1986 and 1996 (Administration on Aging, 2001), even though the older population increased by only 10 percent. About 80 percent of abused elders are women, and those over age 80 are the most frequent victims of abuse.

Media reports give the erroneous impression that elder abuse occurs primarily in nursing homes, but research indicates that most abuse and neglect of elders occurs at home. Most of the time, the perpetrators are spouses or family members (National Center on Elder Abuse, 2002).

Older women in abusive situations are the least likely to report the abuse, primarily due to social and cultural values. A woman brought up in pre-1960s America tends to see her role as obeying her husband without question. Admitting that she's being abused is admitting failure in the relationship. Blaming herself, she feels powerless, hopeless, and embarrassed to seek help.

Domestic abuse by a spouse in later life is generally a continuation of behaviors established early in a marriage. For some, however, abuse may begin in a new relationship after the divorce or death of a partner. For others, a decades-long marriage may become abusive for a variety of reasons: failing health or disability of one partner, retirement, sexual changes, dementia, or use of alcohol or other drugs.

All healthcare providers need to be alert to the possibility of domestic abuse in patients of every age, race, and socioeconomic group. Only when the victims of abuse are identified can they be protected and assisted in resolving their situation.

DOMESTIC VIOLENCE IN FLORIDA

According to the Florida Department of Law Enforcement (2005), the steady increase in Florida domestic violence cases ended in 1998 and is continuing to decline. Between 1992 and 2004, the rate of domestic violence cases (per 100,000 population) declined by 26 percent.

Although this downward trend is encouraging, the number of reported cases of domestic violence exceeded 120,000 in 2006 (Florida Attorney General, 2007). In fiscal year 2003–2004, Florida's domestic violence centers responded to more than 132,000 crisis calls, provided counseling services to nearly 200,000 people, and provided emergency shelter to more than 14,000 people, mostly women and children (Florida Coalition Against Domestic Violence, 2004).

In a Florida survey, most people believed that domestic violence is common, and more than half the population surveyed reporting knowing a victim of domestic violence. The vast majority indicated that treatment should be required for people who have physically abused someone. Most Floridians (85.3%) believe that imprisonment is the appropriate punishment for domestic violence incidents involving serious bodily injury (Florida Department of Corrections, 1999).

An overwhelming majority of Florida taxpayers believe that the state needs to spend more on prevention and treatment of domestic violence and on law enforcement related to domestic violence. More than 7 out of 10 report that they would agree to an increase in taxes to fund more counseling and shelters for abused women (Florida Department of Corrections, 1999).

Florida is 1 of 10 states having participated in the Family Violence Prevention Fund's healthcare initiatives since 1995. These initiatives have resulted in important policy changes concerning reporting domestic violence, training reforms, public education, and outreach into diverse and underserved communities. Florida now requires:

• Health practitioners to take a two-hour domestic violence education course as part of every third relicensure or recertification for medical physicians, osteopathic physicians, anesthesiologist assistants, nurses, midwives, physician assistants, dentists, dental hygienists, licensed clinical social workers, and other healthcare providers. Providers can substitute "end of life care" for the requirement of domestic violence training.
• Healthcare providers and law enforcement authorities to report any gunshot or life-threatening wounds or injuries.
• Judges to inform victims of their rights, including the right to appear, be notified, seek restitution, and make a victim impact statement.
• Clerks of courts to provide victims with information regarding collecting restitution through the enforcement of liens. Posters outlining these rights will be posted in courtrooms under this bill.
• A minimum term of imprisonment (5 days in the county jail) for any person found guilty of a crime of domestic violence and who has intentionally caused bodily harm to another person unless the court sentences the person to a nonsuspended period of incarceration in a state correctional facility.

Florida Statute 626.9541(g)(3) prohibits health, life, and disability insurers, as well as managed-care providers from refusing to issue, reissue, renew, or pay a claim; from canceling a policy; or from increasing rates based upon the fact that the insured or applicant has been a victim of domestic violence.

Florida law has established Batterers' Intervention Programs for perpetrators of domestic violence. Attendance at a batters' intervention program is usually imposed by the court as a condition of probation. Effective July 1, 2002, the batterers' intervention program must be a certified program under s.741.32.

According to the Florida Department of Law Enforcement, 75 percent of those who perpetrate domestic violence are male, and therefore its initial efforts at certification of and setting standards for these programs has focused on programs designed for men who commit acts of domestic violence.

Florida Statute 790.33 prohibits possession of a firearm or ammunition by anyone subject to an injunction against committing acts of domestic violence. Law enforcement officers are exempt from this statute and, according to the earlier-mentioned 1999 survey, 93 percent of Floridians believe this exemption is wrong (Florida Department of Corrections, 1999).

In 2004 the Florida Office of the Attorney General sponsored an initiative called Cut Out Domestic Violence, a program that provides hair-salon professionals with training seminars on domestic violence, its prevalence in Florida, signs of domestic violence, and ways to discuss the topic with clients. Salon professionals are not encouraged or required to report suspected cases of abuse, but serve as a vital resource to victims among their clientele.

Hair salons are one of the few places where an abused woman can go without her abuser. Many salon professionals build relationships with their clients and may notice changes in their behavior that suggest a problem. Women who are being abused may disclose this to a trusted salon professional. Training through Cut Out Domestic Violence can prepare that person to respond with information about resources in her area (Florida Coalition Against Domestic Violence, 2004).

FLORIDA LEGISLATION

In April 2002, Florida's governor signed legislation that strengthened existing domestic violence statutes and amended several statutes to make the definition of domestic violence consistent. According to s.741.28, domestic violence means

…any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury of one family or household member by another family or household member.

"Family or household member" means spouses, former spouses, persons related by blood or marriage, persons who are presently residing together as if a family or who have resided together in the past as if a family, and persons who are parents of a child in common regardless of whether they have been married. With the exception of persons who have a child in common, the family or household members must be currently residing or have in the past resided together in the same single dwelling unit.

The 2002 legislation reduces the burdens for domestic violence victims seeking protective orders by eliminating the filing fee for injunctions prohibiting contact by perpetrators of domestic violence. This bill also ensures that Florida would continue to receive federal funds under the Violence Against Women Act.

The legislation defines "dating violence" as "violence between individuals who have or have had a continuing and significant relationship of a romantic or intimate nature." The existence of such a relationship shall be determined based on the consideration of the following factors:

• A dating relationship must have existed within the past 6 months.
• The nature of the relationship must have been characterized by the expectation of affection or sexual involvement between the parties.
• The frequency and type of interaction between the persons involved in the relationship must have included that the persons have been involved over time and on a continuous basis during the course of a relationship.

It clarifies that those who are in a dating relationship are not required to have resided together to be eligible for an injunction for protection against violence.

The law creates a checklist for domestic violence petitioners to consider when completing the petition and provides a checklist for the court to consider prior to issuing an order. It allows certified domestic violence center advocates, prosecution, or law enforcement advocates to be present during injunction hearings and mandates that all injunction hearings be recorded.

The 2002 legislation also makes it a crime for a respondent to go within 500 feet of the petitioner's residence or within 100 feet of the petitioner's motor vehicle.

On July 1, 2006, the Domestic Violence Center/Trespass Act (also called the Safe Shelter Act) amended s.810.09, F.S., to increase the criminal penalty from a first-degree misdemeanor to a third-degree felony for trespassing upon a certified domestic violence center that is legally posted and properly identified. Violators face a maximum possible penalty of five years in prison (rather than one year in jail) plus a $5,000 fine.

For the felony penalty to apply, a domestic violence center must be certified under s.39.905, F.S., and be legally posted and identified in substantially the following manner: This area is a designated restricted site and anyone who trespasses on this property commits a felony.

HEALTHCARE IMPLICATIONS

Domestic violence has an enormous impact on the healthcare system. Homicide, injury, mental illness, substance abuse, and the legacy of violence from generation to generation may all be related to domestic violence. Women are the most frequent consumers of healthcare services and the most common victims of domestic violence. This puts healthcare providers in the best position to identify victims of domestic violence and make appropriate referrals to protect them against further harm.

As the single most important and most accessed institution in the lives of women, the healthcare setting can provide a unique opportunity to intervene, making it one of the newest and most critical areas of the domestic violence movement today. (Family Violence Prevention Fund, 2001)

The shame and fear surrounding domestic violence silences many victims. Research shows that at least 4 out of 10 incidents of domestic violence are not reported to the police (Durose et al., 2005). Many abused women do not report IPV to their physicians or to anyone else.

Even though many healthcare providers are alert to signs of potential child abuse, too few screen for IPV. According to a recent poll, one-third of U.S. physicians surveyed said that they don't record patients' reports of domestic violence and 90 percent don't document whether patients are offered information or other support. One-third of physicians surveyed admitted that they did not feel confident about counseling patients who reported IPV (Gerber, 2005).

Research also indicates that physicians often fail to screen for elder abuse. Even though the rate of elder abuse is estimated at up to 10 percent of people over 65, only 2 percent of reported elder abuse cases come through physicians. One study of primary care physicians showed that more than half had never asked their elderly patients about abuse (Kennedy, 2005).

A survey of managed care organizations showed that less than one-third of HMOs in the United States have policies, protocols, guidelines, or materials on screening for domestic violence (National Health Resource Center on Domestic Violence, 1999).

RISK FACTORS FOR DOMESTIC VIOLENCE

Poverty

Poverty damages health and well being in countless ways—exposure to domestic violence is just one. Research shows that between 9% and 23% of women receiving welfare report being abused within the past 12 months. More than 50% of women receiving welfare report having experienced physical abuse at some point during their adult lives (Lyon, 2000).

Poor women in abusive relationships have complicated lives and inadequate coping resources. They face risks from the batterer and risks resulting from their poverty. Risks from the batterer include physical injury, threats and loss of security, housing, and income, and potential loss of their children. Risks resulting from poverty include lack of access to health insurance and health care, possibly racism, unsafe neighborhoods, and poor schools for their children (Davies, 2002).

These risks pose complex challenges to abused women and to the healthcare and social service professionals responsible for protecting them. Intervening to stop the violence is only the first step. Issues of income, housing, and healthcare—both mental and physical—must also be addressed.

Family/Caregiver Stress

Families stressed by illness, unemployment, alcohol, and/or drug use are more likely to experience violence. This is particularly true with elder abuse, especially if the older person is frail or mentally impaired, the caregiver is ill-prepared for the task, or if needed resources are unavailable. Adult children who abuse their parents frequently suffer from mental and emotional disorders, alcoholism, drug addiction, and/or financial problems that make them dependent on the parents for support.

Violence is a learned behavior and creates a painful legacy in some families. These families respond to tension or conflict with violence because they have not learned any other way to respond.

Pregnancy

Pregnancy may trigger or intensify domestic violence, particularly if the male partner is unemployed or sees the child as a rival for the woman's time and attention. Violence occurs in up to 8 percent of pregnancies and is particularly associated with unplanned pregnancy. More than 300,000 women each year experience IPV during their pregnancy (Gazmararian et al., 2000).

Battering can lead to high blood pressure or edema, vaginal bleeding, kidney or urinary tract infection, miscarriage, preterm labor, low birthweight, or other injury to the developing fetus (Silverman et al., 2006). Maternal mortality is three times as high for abused mothers, and abused African American mothers are four times as likely to die as their white counterparts. IPV also increases the risk of fetal death, approximately 16 per 1000 affected pregnancies (Boy & Salihu, 2004). The stress of abuse may also cause pregnant women to continue such unhealthy habits as smoking and drug or alcohol use.

Researchers at the CDC found that homicide was a leading cause of injury deaths among pregnant and postpartum women in the United States during the 1990s (Chang et al., 2005). Risk factors for pregnancy-related homicide included: age younger than 20 years, African American, and late or no prenatal care. Firearms were the most common method of homicide. Earlier studies in Maryland and Massachusetts also identified homicide as a leading cause of pregnancy-related death (Horon & Cheng, 2001; Nannini et al., 2002).

Disability/Impairment

The erroneous assumption that women with disabilities are asexual has not freed them from sexual abuse. R. Amy Elman Confronting the Sexual Abuse of Women with Disabilities

People with disabilities, especially women, may be at higher risk for IPV, particularly sexual violence, than people without disabilities. The perpetrators of domestic sexual violence are most often male caregivers who may be family members. Sexual violence includes sexual abuse, sexual assault, and rape. Disability is defined as "limitations in physical or mental function, caused by one or more health conditions, in carrying out socially defined tasks and roles that individuals generally are expected to be able to do" (Institute of Medicine, 1991).

Florida Law (Chapter 415 F.S.) classifies people with disabilities who may be unable to adequately provide for their own care and protection as vulnerable adults and requires that healthcare providers report suspected abuse, neglect, or exploitation to the Florida Abuse Hotline. See Reporting Requirements for Domestic Violence in Florida below.

According to the CDC, between one-fourth and two-thirds of adults with cognitive impairments experience sexual violence; rates of sexual violence among women with cognitive disabilities range up to 79 percent. Reported rates among adolescent boys with disabilities range up to 6 percent, while reported rates for adolescent girls with disabilities are about 24 percent.

Research indicates that women with disabilities have similar rates of IPV compared with women who do not have disabilities. However, those who have a disability experience abuse for longer periods of time. Having a disability limits a woman's options for escaping or resolving the abuse. For example, if an abusive partner withholds needed equipment, such as a wheelchair, or assistance with dressing or getting out of bed, it prevents access to programs that could help end the abuse (Nosek et al., 2001).

Women living with HIV also can be at increased risk for IPV. According to the National Women's Health Information Center, many HIV-positive women report emotional, physical, or sexual abuse at some time after their diagnosis.

SCREENING AND ASSESSMENT

Every healthcare facility serving women, children, and older adults needs to screen for potential domestic violence. This screening need not be lengthy. In fact, researchers have developed an effective two-minute assessment screen for early detection of abuse of women (Brown et al., 1996) (Table 1). The screening can be part of the intake interview or included as part of the written history.

TABLE 1

SCREENING TOOL FOR ABUSE OF WOMEN

Question	Circle best answer
1. In general, how would you describe your relationship?	a lot of tension	some tension	no tension
2. Do you and your partner work out arguments with ...	great difficulty	some difficulty	no difficulty
3. Do arguments ever result in you feeling put down or bad about yourself?	often	sometimes	never
4. Do arguments ever result in hitting, kicking, or pushing?	often	sometimes	never
5. Do you ever feel frightened by what your partner says or does?	often	sometimes	never
6. Has your partner ever abused you physically?	often	sometimes	never
7. Has your partner ever abused you emotionally?	often	sometimes	never
8. Has your partner ever abused you sexually?	often	sometimes	never
Source: Centre for Studies in Family Medicine, n.d. Used with permission.

Signs and Symptoms Related to IPV

Healthcare providers should be alert for signs and symptoms that may be related to IPV. Delay in seeking care, missed appointments, and vague or inconsistent explanation of injuries or nonspecific somatic complaints should be noted. Depression and social isolation are common, as are substance abuse and use of alcohol or drugs.

During the appointment, be aware of lack of eye contact and/or a husband or boyfriend who is reluctant to leave the woman alone with the healthcare provider. Victims of abuse may appear fearful, anxious, withdrawn, angry, nonresponsive or afraid to talk openly. Suicide attempts may be directly related to IPV.

During the physical examination, look for injuries on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals. Note any bruises, burns, or wounds shaped like objects such as teeth, hands, belts, or cigarette tips. Note any pain from touching. Be alert for puncture wounds, fractures and dislocations, scars on the vulva or rectum, or any unexplained vaginal or anal bleeding, particularly in older people. Be aware that the woman may wear a glove or sock to conceal a scalded hand or foot.

Documenting Suspected Domestic Violence

Accurate, thorough documentation of the patient's injuries is essential in cases of suspected abuse because it can serve as objective, third-party evidence useful in legal proceedings. For example, medical records can help victims to obtain a restraining order, or to qualify for public housing, welfare, health and life insurance, and immigration relief.

To be admissible in a court of law, medical documentation should include the following (Isaac & Enos, 2001):

• Photographs of the injuries, taken during the initial examination.
• Body maps, which document the extent and location of the injuries.
• Description of the patient's demeanor (crying, angry, agitated, upset), including a record of the patient's comments about how the injuries occurred. The patient's own words should be set off in quotation marks or identified by such phrases as "the patient states" or "the patient reports."
• Any description in which the patient identifies the abuser, such as "my boyfriend kicked me."
• The time of day when the patient is examined and, if possible, how much elapsed time since the injuries occurred. For example, "patient says that last night her husband punched her."
• Legible handwriting. Too often, doctors' or nurses' poor handwriting on medical records makes the documentation inadmissible as evidence.

Health professionals should avoid any phrases—such as "patient claims" or "patient alleges"—that cast doubt on the patient's reliability. Also avoid legal terms such as "alleged perpetrator" or "assailant." Do not use conclusive terms such as "assault and battery" or "domestic violence" in documenting a case; let the factual information in the record speak for itself.

REPORTING REQUIREMENTS IN FLORIDA

Child Abuse

Child abuse and neglect is defined in the federal Child Abuse Prevention and Treatment Act (CAPTA) as "any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm." Child abuse can include physical abuse, substance abuse, neglect, sexual abuse/exploitation, emotional abuse, and abandonment (Child Welfare Information Gateway, 2005).

Chapter 39 of the Florida statutes mandates that any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare shall report immediately such knowledge or suspicion to the Florida Abuse Hotline of the Department of Children and Families: 1-800-96-ABUSE (1-800-962-2873).

All healthcare professionals are required to provide their name to the hotline staff. The name of the person reporting shall be entered into the record of the report but shall be held confidential, as provided in s.39.202, F.S.

The name of any person reporting child abuse, abandonment, or neglect may not be released to any person other than employees of the department responsible for child protective services, the central abuse hotline, law enforcement, or the appropriate state attorney, without the written consent of the person reporting. This does not prohibit the subpoenaing of a person reporting child abuse, abandonment, or neglect when deemed necessary by the court, the state attorney, or the department, provided the fact that such person made the report is not disclosed.

The healthcare provider should be prepared to describe:

• Victim name, address or location, approximate age, race, and sex
• Signs or indications of harm or injury, including a physical description if possible
• Relationship of the alleged perpetrator to the victim, if possible. If the relationship is unknown, a report will still be taken if other reporting criteria are met.

Vulnerable Adult Abuse

As mentioned earlier, Florida law requires healthcare providers to report suspected abuse of vulnerable adults to the Florida Abuse Hotline. Abuse means any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult's physical mental, or emotional health. Abuse includes acts and omissions (415.102(1), F.S.). All reports are confidential, including the name of the reporter. Box 1 provides a list of the occupations required to report suspected abuse of vulnerable adults.

In 2006, the Adult Protective Services statute was amended to enable the Department of Children and Families (DCF) to petition the court for an order authorizing the provision of protective services if a vulnerable adult in need of protective services is being abused, neglected, or exploited but lacks the capacity to consent to the provision of protective services (415.105(1), F.S.). In addition, the statute now enables the Agency for Persons with Disabilities (APD) to gain access to information in the central abuse hotline data (415.107, F.S.).

Intimate Partner Abuse

Florida statute 790.24 requires healthcare providers to report gunshot or life-threatening wounds or injuries. Obviously, this does not cover the majority of injuries sustained in IPV. However, reporting suspected domestic violence without the informed consent of the woman is unethical and may cause the abuser to retaliate.

Elder Abuse

Florida statute requires that all health professionals, including employees of long-term care facilities, report known or suspected cases of elder abuse.

PATIENT AND FAMILY INTERVENTIONS

Care of the Abused Woman

Begin by believing any woman who admits being abused. She has shown trust and courage to disclose the facts. Skillful, nonjudgmental interviewing can help build trust and establish a therapeutic relationship. Holtz and Furniss (1993) developed guidelines for care of the abused woman called the ABCDES Framework:

A     Assure the woman she is not alone. Isolation enforced by her abusive partner prevents her understanding that others are in a similar situation and that health care providers can help.

B     Express the belief that violence against the woman is unacceptable in any situation and that it is not her fault.

C     Ensure confidentiality. She may fear (justifiably) that the abuser will retaliate.

D     Document the case thoroughly (see above).

E     Educate the woman about the cycle of violence (Box 2), the likelihood of repeated violence, and her options for ending the abuse.

S     Safety. Help the woman formulate a plan of action for either leaving or remaining in the relationship, which some women do for a variety of reasons. Provide information about available resources such as hotline and shelter numbers. Suggest that a quick getaway bag packed with personal items be hidden or left with a neighbor. If possible, the woman should have an extra set of car keys, house keys, money, and any legal documents needed for identification.

Women with children should take them along to prevent their being abused or held hostage by the abuser. One woman in an abusive relationship had her children go to bed with their shoes on so they could escape at a moment's notice if their alcoholic father became violent. She trained them to run to the neighbors and ask them to call the police. Children whose mothers are being abused need help in protecting themselves. Depending on their age, children can:

• Learn when the cycle of violence is most likely to occur.
• Recognize the clues that suggest the abuser is getting upset.
• Watch for signs of drinking or drug abuse by the abuser.
• Avoid behaviors that may worsen the abuser's stress.
• Avoid areas of the house where violence usually occurs.
• Leave the house when domestic violence starts.
• Arrange to stay with a friend or relative and be honest about what is happening.

COSTS AND POLICY IMPLICATIONS

IPV is common, chronic, and produces negative effects on women's physical and mental health that are as severe as cancer or diabetes, and that add an enormous economic burden to health care systems. Development, implementation, and evaluations of systems for the secondary prevention of IPV are not only warranted, they are urgently needed. Robert S. Thompson, MD Quoted in DeClare, 2007

Domestic violence exacts a high price on its victims and on families, communities, and society as a whole. In human terms, the costs are impossible to measure. Violence and the injuries, arrests, and harassment that result can destroy health, family, and life itself.

In economic terms, the costs of IPV against women are staggering, exceeding $8.3 billion in 2003 (CDC, 2005). These costs include $460 million for rape, $6.2 billion for physical assault, $461 million for stalking, and $1.2 billion in the value of lost lives (Max et al., 2004). The average medical cost for women who experience domestic violence is $483, compared to $83 for men.

This study found that IPV against women resulted in more emergency room visits and hospitalizations than in cases where men were the victims (Arias & Corso, 2005). Prevention of domestic violence and early identification and treatment of victims would likely benefit all healthcare systems in the long run, and would eliminate much pain and suffering for survivors of IPV.

Scientists at the University of Washington found that total healthcare costs were 19 percent higher in women with a history of IPV than in women who had not experienced IPV. They also reported that these higher healthcare costs persisted five years after the abuse ended (Rivara, et al, 2007).

Healthy People 2010 named injury and violence as one of the ten leading health indicators that will be used to measure the health of the United States during the first ten years of the twenty-first century. Health professionals can make a critical difference in the progress toward ending this costly, destructive epidemic and halting the transmission of violence from generation to generation.

Parallel Justice

Our society devotes enormous resources to apprehending, prosecuting, punishing, and rehabilitating perpetrators of crimes such as domestic violence. However, victims often receive little or no support to help them recover. The National Center for Victims of Crime (NCVC) seeks to change that inequity through an initiative called the Parallel Justice Project. This initiative "elevates the goal of helping victims rebuild their lives to a fundamental component of justice…. Under a system of Parallel Justice, the societal message to victims would be 'What happened to you is wrong and we will help you rebuild your life.'"

The NCVC has been working with three communities to test the feasibility of implementing the Parallel Justice concept at the local level. The communities are Burlington, Vermont; Redlands, California; and Winston-Salem, North Carolina. More information is available on the NCVC website: www.ncvc.org.

COMMUNITY, STATE AND NATIONAL RESOURCES

Most communities have child protective services and adult protective services agencies to which known or suspected cases of abuse should be reported. Appended to this course is a list of resources including domestic violence hotlines and websites that may be of help to the health practitioner who is seeking more information on this topic.

Posted April 4, 2007

Expires May 1, 2009

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