Course Description

In July 1995, the State of Florida legislature approved the addition of Domestic Violence as a licensure requirement for specific healthcare professionals. The Domestic Violence program presented here meets the mandated requirements of this legislation. This program contains components that include information about domestic violence and the risk factors associated with Domestic Violence and AIDS. The program will give a statistical approach specific to professional practice and the incidence of domestic violence within that practice. Assessment techniques, interview techniques and proper documentation of domestic violence will be reviewed in detail. Referral information, hot lines, crisis centers, etc. will be provided.

Course Objectives

Demonstrate an understanding of the broad spectrum that domestic violence encompasses.
Identify statistical incidence of domestic violence as it relates to each individual practitioner.
Discuss why domestic violence occurs.
List the reasons victims of domestic violence often stay in abusive relationships.
Discuss the reluctance of the medical community to intervene in domestic violence.
Identify physical indicators of abuse in women, children, and the elderly.
Clearly document abuse in the patient's medical record.
Identify the need for establishing protocols in health care settings for assisting victims and perpetrators of domestic violence.
Provide victims and perpetrators with sources of assistance.

Who are Victims of Domestic Violence?

The definition of domestic violence varies from source to source. In addition there are multiple terms used, but the most frequently used in professional environments “intimated partner violence.” This term specifically refers to violence occurring between two individuals that have had an intimate relationship in the past, including marriage. However, domestic violence can be extended to include children, and elders living or have lived in the same household and/or had a very close connection to the perpetrator (Burnette & Adeler, 2006). Domestic violence is a repetitive pattern of coercion by a competent adolescent or individual in which the aim is to gain and maintain control over another individual. These behaviors can occur alone or in combination, can happen regularly or sporadically and include physical and emotional abuse, and nonconsentual sexual behavior (Burnett, 2006). Domestic violence lasts along a continuum from a single episode to ongoing episodes of physical or emotional abuse (CDC, 2006).

Women are beaten almost every 9 seconds in the United Sates. Annually, approximately 4.8 million women are victims of domestic violence physical assaults and/or rapes. Experts state that in the course of their lifetime, nearly one in four women will experience domestic violence at some point in her lifetime (approximately 25 percent of women). However, women are not alone in the domestic violence issue, each year 2.9 million men experience domestic related assaults. Domestic violence may also apply to others leaving with (past or presently) with the perpetrator, including children, elderly adults, and others (CDC, 2006).

No discussion of domestic violence would be complete without addressing the problem of child abuse. Partner abuse and child abuse frequently co-exist. Several studies have shown that between 45 and 70 percent of men who battered a wife or girlfriend also abused a child. (Jones, 1994). The true incidence of child abuse is unknown, but it is conservatively estimated that over 1,000,000 children nationwide are abused and/or neglected annually.

There are four types of Domestic Violence:

Physical Abuse - This is the use of physical force against a partner or other household member. Includes hitting, striking, biting, and shoving the victim. Other less violent forms include pinching, or scratching. Physical harm to the victim does not have to occur
Sexual Abuse - This is a forced non-consensual act or attempted act of sexual intercourse with the victim. The force may be physical or emotional in nature.
Threats - Threats may be of a sexual or physical nature. The threats may involve actual or perceived harm to the victim or family members of the victim such as children, elders, or even pets.
Emotional Abuse - Involves threats to the victim or family. Destruction of the victim’s self esteem, name calling or other attacks on character or social standing. May also involve preventing the victim from interaction with friends, family, or other social encounters. This also includes stalking (CDC, 2006).

Risk Factors for Domestic Violence:

Any person with a disability is at risk for domestic violence
Pregnancy
Family income below $10,000
Females with higher educational or occupational levels have a higher risk of abuse .
History of family violence
Alcohol or drug abuse by either the victim or batterer
Current abusive relationship
History of psychiatric disorders
History of abuse as a child

Isn’t Domestic Violence Just a Social Issue?

No, domestic violence is more than a social issue, it’s a health issue as well. According to the CDC, in 2004 there were 1,544 deaths from domestic violence with 3 of 4 victims being women. In 1995, the cost of domestic violence, for mental, medical, and lost wages were 5.8 billion dollars and in 2003, 8.3 billion dollars. (CDC, 2006). We should always be mindful that the emotional and physiological effects can last much longer that the physical affects.

In a study of eighth and ninth graders, 25% indicated that they had been victims of dating violence. One in every eight pregnant adolescents reports being abused by the father of her child (Nelson, 2006). Adolescents and young adult women are 25% more likely to be victims of domestic violence than any other age group.

Florida and Domestic Violence

Florida had 115,170 cases of domestic violence in 2006, 54% of these cases ended in an arrest. There were 1,089 forcible rapes, 369 forcible sodomy cases, and 947 cases of forcible fondling reported in 2006. Thirty-five percent of the forcible sex offenses had arrests made in the case. In 2006, 164 domestic violence homicides were counted.

Florida law defines domestic violence as “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 or death of one family or household member by another who is or was residing in the same single dwelling unit” (Allen, 2006).

In 2001, Florida Governor Jeb Bush signed into law the Family Protection Act that requires a mandatory 5-day jail term for any crime of domestic battery in which the abuser deliberately injures a victim. This law also mandates that a second act of battery becomes a felony offense. In 2002, Florida law was amended to include any dating relationship of at least 6 months duration in the definition of domestic violence (Allen, 2006).

Guns and Domestic Violence (Violence Policy Center, 2005)

One study of domestic violence revealed that women are more likely to be murdered with a firearm than all other methods combined stressing the importance of limiting accessibility of firearms to persons with a history of domestic violence. Also, gun don’t actually need to be fired to be used in domestic violence. Often abusers use firearms to intimidate or coerce a victim and allow the abuser to have feelings of power, domination, and leverage.

A 2003 study highlighted that a woman with a gun present in the home is three times more likely to be murdered than a woman with no gun in the home. This is alarming as most domestic violence occurs at home more than any other setting. “Furthermore, women who were murdered were more likely, not less, to have purchased a handgun in the three years immediately prior to their death, negating the myth that the purchase of a handgun by a woman furthers her safety.”

A 2005 FBI report of 1,858 female homicides that involved single female victim/single male offender reveals a lot of myth shattering facts:

In cases where the relationship between the victim and the offender could be identified, 92 percent of the victims were murdered by someone that they knew.
More than 12 times more females are murdered by a male known to them than by a male stranger.
For victims who knew their attacker, 62 percent of females were wives or intimate acquaintances of the offenders
317 of the female victims were shot by their husband or intimate partner during the course of an argument.
Nationwide 52 percent of female homicides were committed with firearms. Knives or other cutting instruments accounted for 21 percent of all female homicides. Bodily force accounted for 14 percent of the homicides and blunt objects accounted for seven percent of the weapons used against female victims.
Of homicides committed with firearms, handguns were used in 72 percent of cases
Eighty-nine percent of the homicides were not related to the commission of other felonies such as rape or robbery.
In most homicides, the victim and the offender are of the same race.
The average age of female victims is 38 years old.

For African American women, the rate of homicide is 3 times that of white females, and African American women are just as likely as white women to know their assailant. Compared to a man, a black woman is far more likely to be killed by a spouse, intimate partner, or a family member than by a male stranger. In 2005, 12% of black homicide victims were less than 18 years old. 4% of victims were over age 62 years. The average age of a black female homicide victim is 33 years old.

Domestic Violence and the Law

In the 1990’s, two major laws were enacted to help prevent domestic abusers from obtaining firearms.

Wellstone Amendment (1994) - prohibited individuals who are . the subject of a protective order from buying or possessing firearms. Twenty states also have state laws to supplement the federal law.
Federal Law (1996) - a provision to the Federal law was made prohibiting persons with misdemeanor domestic violence offenses from purchasing or possessing firearms, essentially ensuring that felony convictions of domestic violence are already precluded from firearms possession due to the nature of felony commission.
The Brady Bill allows requires a criminal background check through National Instant Criminal Background Check System (NICS) for any person purchasing a firearm through a Federal Firearms License holder. There are 2 domestic violence categories, which are responsible for 16% of overall firearm rejections. Note: Not all states have made misdemeanors and protective orders available in NICS.

Ranking

State

# of Homicides

Homicide Rate per 100K

Nevada

2.53

Alaska

2.49

Louisiana

2.16

New Mexico

2.15

Mississippi

2.00

Arkansas

1.98

South Carolina

1.97

Alabama

1.88

Tennessee

1.87

Oklahoma

1.84

Number of Females Murdered by Males in Single Victim/Single Offender Homicides and Rates by State in 2005,

Ranked by Rat

Identification of Abuse

“It is estimated in the United States that police officers spend approximately one-third of their time responding to domestic violence calls. When asked where they would seek help when faced with domestic violence thirty-one percent responded that they would attempt to obtain help from the police and 14.7 % responded that they would go to a hospital. However, a study in the Northwest revealed that 95% of women victims of domestic violence sought care 5 or more times in a year. Almost a quarter of those sought care more than 20 times a year. Most go to an emergency room” (Burnett, 2006).

These numbers indicate that doctors and nurses are the ideal person to identify and intervene in domestic violence situations. However, research reflects screening rates for health care providers continue to be very low. Under a third screen for domestic violence on a routine basis (Nelson, 2006). There continue to be an array of initiatives to help fight domestic violence and raising awareness within the community. Some of the most frequent initiatives are direct screening, poster campaigns, placing numbers of local domestic violence shelters in female restrooms. Since abusers are likely present or close by during healthcare visits, female restrooms are great places for the healthcare team to target domestic violence victims.

It is also important to note that domestic violence may exist upon elderly parents of an abusive adult child. An adult child who lives in the home of the parent and is dependent upon the parent for financial support may be in a position to inflict abuse (Allen, 2006). The abuse may not be manifested as violent act s, but may lead to a position where the elder is controlled and isolated. The elder may fear the loss of the adult child’s presence as caregiver, and therefore, not be willing to disclose the dominating situation.

Barriers to effective intervention have been identified among health care personnel. If requests for help are not specifically verbalized by the patient, interventions for domestic violence and abuse frequently are not initiated. Some of the barriers to domestic violence intervention are:

Social Factors: Implied or expected social norms, tolerance of domestic violence within the area, and cognitive immunity to the problem as a result of epidemic exposure.
Personal Factors: Gender bias, personal abuse history, idealization of the family unit, privacy issues, feeling that one case will not change the big picture.
Professional Factors: Time and staffing issues, personal comfort with handling domestic violence, inexperience with handling domestic issues, professional detachment or inversely professional involvement with the abuser or the victim.
Legal Factors: Lack of education or clear facility policies and positions on intervention. Concern over possible legal ramifications. .
Making judgments about the victim, their choices, or lifestyle. ‘Profiling’ the typical domestic violence victim.

“When assessing a patient, we need to adopt a suspicious wariness to domestic violence and consider it as a differential diagnosis in a vast number of medical complaints. The patient may not even be aware that the true root of the physical problems rests with the experience of domestic violence. Less than 1 in 25 women receive an accurate diagnosis “(Barnett, 2006).

Cycle of Domestic Violence

Domestic Violence follows a predictable and repeating pattern. This pattern is termed the cycle of violence and consists of three components:

Tension building
Explosion followed by battering
Absence of tension, also called loving respite, honeymoon phase, reconciliation.

It’s important that healthcare providers understand the cycle of domestic violence in order to effectively identify its presence. During the tension-building phase, the victim attempts to be exceedingly compliant to the abuser in the hopes of preventing another episode of battering. Regardless of the effort upon the part of the victim, the abuser continues to become increasingly angry. Sometimes the victim will dread the battering episodes so horribly, that they either will consciously or unconsciously precipitate the event in order to get the battering episode over with. After the battering episode concludes, the abuser becomes very remorseful and loving for a period of time. As the cycle of violence deepens the time between episodes grows shorter and the battering episodes more intense.

Characteristics of Abusers

Characteristics of abususers haven’t been studied as much as the victims, but researchers have been able to idenfiy some trending characteristics. The following are a few characteristics of abusive relationships.

Frequent consumption of alcohol or drugs
Abusers tend to be very controlling of the victim or family activities, even to the point of paranoia.
Abusers tend to demonstrate jealous or possessive. The domination tends to be all-compassive, to the point of compulsion. (Allen, 2007).
Extreme dependence one upon the other. Each partner in the relationship has a tendency to believe that they will perish without the other. (Allen, 2007).

How Victims Cope with Domestic Violence

Domestic violence victims use a variety of coping mechanisms to help them deal with the abuse until they can find a way out of the abusive situation. However, these coping mechanisms can sometimes be barriers to the victim receiving the help that they so desperately need. Identified coping mechanisms in domestic violence victims and their characteristics are: .

Denial -The abused denies that the abuse is actually happening or tries to deny the degree of abuse and its impact on er. This is manifested by excusing the bruises, “I ran into the door.” “It was an accident, he didn’t mean to do it.” Denial helps the victim cope by avoiding feelings of terror and humiliation.
Minimization is closely linked to denial. With minimization, the victim attempts to rationalize that the abuse is less serious than it is. May make statements such as: “this isn’t abuse, abuse is much more serious,” or, “he only hit me once with his fist.”
Nightmares help the victim by allowing the playing out in the mind of thoughts and feelings that are too horrible to be experienced during waking moments. These feelings may involve fear, anger, panic, and shame
Shock and Disassociation are feelings help to numb the mind of the victim so that the true impact of the abuse does not occur until the victim is in a safer environment with which to confront the emotions. These coping mechanisms may continue even after the victim reaches safety, until they are no longer needed or they are no longer helpful. At this point, the victim may be in a position to receive support services.

Persons who are repeatedly exposed to a negative and unpredictable environment may begin to exhibit signs of stress response with self-blame, chronic anxiety, inward turning of anger, denial of anger toward the batter, passivity, and paralyzing terror at the first signs of danger. This results in a form of learned helplessness on the part of the victim.

Why do Victims Stay

There are four main reasons victim often stays within reach of the abuser: (1)love (2) hope (3)dependence (4) fear. The victim is afraid of losing the perceived love of the batterer and hopes that things will change with hopes everything will be okay. Victims often do not want to get their abuser in trouble (particularly with law enforcement) or may have concerns regarding how they will survive financially, especially when children are involved. Victims may fear that the violence would escalate if they attempt to leave, and often it does. The most dangerous time for a victim is during times of separation. Often the abuser will kidnap children in retaliation for the separation (Burnett, 2006).

Knowing the cycle of violence and being able to assess which stage of violence that the victim is in gives the healthcare provider increased leverage in helping the victim. During the tension building and battering phases, the patient is going to be the most willing to receive help. During the reconciliation phase, the abuser has convinced the victim that the abuse will never happen again and therefore the patient is in a state of unwillingness to receive help in the face of being showered by the love of the abuser.

Understanding the Prochaska Model of Change gives the healthcare provider better insight into the stages in which a victim might be most willing to receive help. These stages of change are hallmarked by certain behaviors and thought processes of the victim.

· Precontemplation- In this stage the victim of abuse has no thoughts of change. The victim may even feel that they are deserving of the abusive treatment that they have received. Persons who are unwilling or unable to change are classified at this stage. In Precontemplation, the victim will be unwilling to receive help. However, inquiry on the part of health care providers will alert the victim that they are in an abnormal state and move the victim toward contemplation.

· Contemplation- This can be a prolonged stage on the road to change, perhaps lasting for years. The victim realizes that a problem exists and begins to weigh the pro and cons of removing themselves from the abuser. However, in this stage the victim is still not ready to expose the abuser. This may be closely followed by a disclosure phase in which the victim finally discusses the abuse with the healthcare provider. The role of the healthcare provider at the stage of disclosure has four elements that need to be met.

o Validate and affirm that the victim is being abused

o Inform the victim about local domestic violence resources

o Educate the victim about effects of abuse on themselves and others

o Document the abuse in the medical record.

· Preparation- In this stage the victim begins to arm themselves with the information and resources necessary for change. This is the stage in which the victim actually plans to leave the abuser.

· Action – This is the stage in which the victim actually leaves the abuser. This stage is frequently reached when the violence extends to or is witnessed by children

· Maintenance- In this stage of change, the change is solidified and progress is made toward preventing relapse. Sadly, many women leave an abuser and return to them, often many times, before this stage is solidified (Burnett, 2006).

Signs of Domestic Violence

The patient who is a victim of domestic violence may have a history of multiple care providers, but only a few visits made to each one, or the patient may have repeated visits with vague symptoms and multiple complaints (Nelson, 2006).

Physical symptoms include multiple bruises with different healing stages, bruises or marks that resemble the hands or fingers. The bruises are usually in areas that can be easily covered up. The patient may have a history of multiple fractures or fractures present for which treatment was never sought. The abuse victim may exhibit a withdrawn personality, be vague in answering questions, and frequently misses or cancels appointments. Appointments that are cancelled by someone other than the patient, especially a domestic partner should be a red flag signal.

A patient who is pregnant may have bruises to the abdomen, and may have late entry into prenatal care. An overbearing partner may accompany the patient when medical care is sought and answer all questions for the patient (Nelson, 2006).

Surface Skin Marks:

Location: The location of the injury is a significant criterion which can aid identification of its origin. Injuries to the thighs, calves, genitals, buttocks, cheeks, earlobes, lips, neck and back are more likely a result of abuse than injuries to the elbows, knees, shins and hands, which are frequently incurred accidentally. Bruises over the bony parts of the child's body (e.g., chin and forehead) are common sites for falling injuries. Bruises to any infant should be particularly suspect given the infant's limited mobility and opportunity for self harm.

Objects Causing Skin Marks: The shape of a surface skin mark or pattern of skin marks provide other clues to origin. Bruises which have distinct configurations or which resemble instruments should be immediately suspect. Samples of objects which cause distinct surface skin marks include:

· belts, belt buckles, ropes and straps

· electrical cords

· hands (palms and fists), feet, knees, and elbows ;

· mop or broom handles, sticks or other pieces of wood

· wire or wood coat hangers

· brushes and combs

· cooking utensils (e.g., spatulas)

· knives, scissors

· hot liquids

· electric appliances (e.g., irons, heating coils)

· radiators and lighted cigarettes, matches or lighters

Marks encircling the child's wrists, ankles or neck may be the result of being tied or restrained. Multiple bruises extending out or downward from the corner of the child's mouth may indicate that he has been gagged. The child who has been grabbed around the torso by another person's hands may show fingerprints in a pattern that clearly denote the pressure applied--eight fingerprints on one side of the torso and two thumb prints on the other side.

Bruises: Multiple bruises on various parts of the body and in various stages of healing should receive particular attention. One way to determine the approximate age of a given bruise is by the color. The following lists the color of bruises and associated age.

Age Color

0-2 days swollen, tender

0-5 days red, blue, purple

5-7 days green

7-10 days yellow

10-14 days brown

2-4 weeks clear

In addition to color differentiation, injuries incurred at different times will reveal older and newer scars. Bilateral eye and facial injuries are of a suspicious origin because only one side of the face is usually injured as the result of an accident. You should be aware that certain birthmarks, in particular ‘Mongolian Spots,’ which can be mistaken for bruises.

Bite Marks: All bite marks should be suspected as the by-product of abuse or neglect. A bite will be evidenced by a mark in the shape of the cutting edges of the teeth. Human bite marks differ in a number of ways from those of animals (including dogs, cats, and rodents). In general, animal bites have a narrower arch form (shape) than human bites, leave deeper and narrower marks, and tend to have a ripping rather than crushing effect.

Mouth Injuries: By-products of trauma to a child's mouth include broken teeth, lip injuries or tears to the frenum (the fold of skin under the tongue). The latter may be the result of the forcing of an object (e.g., spoon, baby bottle) into an infant's mouth and is generally not coupled with other injuries. Although it is possible for a toddler to accidentally incur such an injury after beginning to walk, infants less than six months old will not incur such accidental injuries.

Burns: The extent and characteristics of burn injuries reflect the way the injury occurred. For example, cigarette, match tip, or incense burns produce circular lesions with blisters and ulcers. A lesion is an injury to the body from any cause that results in damage or loss of structure or function of the body tissue involved. Old burns are seen as pigmented scars. The palms, soles, torso, and buttocks are the most common sites of these types of burns.

Dry Contact Burns: Dry contact burns from forced contact with devices or instruments which conduct heat (e.g., irons, eating coils, radiators), usually produce second degree burns which do not form blisters, The injury resembles the contour and shape of the instrument. It is unlikely than an accidental fall against one of these objects will cause an injury of this severity because the child wouldn't remain in contact with the device for more than an instant.

Scalding: Scalding burns are a result of dipping a child into hot liquid or pouring it over the skin. The burn appears uniform in those areas which were exposed to the hot substance with a line separating the burned area from the unburned skin. Stocking burns refer to the injury that results when a child's feet are submerged in a not liquid. Glove burns are caused when the child's hands are forcibly submerged in a hot liquid. Another type is a dunking burn in which the scalding injury is to the feet, buttocks and perineum, corresponding to the child's posture during submersion.

Head Injuries: Violent pulling of a child's hair may cause bleeding under the skin surface, swelling of the scalp, and the simultaneous loss of hair resulting in bald spots or patches. ***Subdural Hematoma, (bleeding between the brain and the skull) is caused when the vein bridging the two is tom. This injury can result from a fall, a direct blow to the head or violent shaking. The presence of swelling and bruises to the scalp, bleeding of the eye, vomiting, seizures, or a coma (or other loss of consciousness), should alert you to the possibility of this type of injury.

Sexual Abuse: A person who has been sexually abused may have difficulty in walking or sitting; pain or itching in the genital area; and bruises, tearing, swelling or bleeding of the external genitalia, vaginal or anal areas, or the mouth. Infections of the vagina and lower urinary tract, venereal disease in pre-pubescent children, the presence of sperm in the rectum, vagina, vulva or perineum, or on the child's clothing, and pregnancy are obvious indications of sexual abuse.

Physical Neglect and Children: Physical neglect results when a parent fails to provide for the child's basic physical needs. This can manifest itself in a number of ways.

· Failure-To-Thrive Syndrome - The child's weight, height and motor development fall significantly below the average grown rate of normal children (i.e., below the 5th percentile). The child appears malnourished, with a noticeable absence of fatty tissue. The child may not respond to cuddling, may not engage in eye contact and / or may have an expressionless face.

· Nutritional deprivation (malnutrition) - A child who lacks sufficient quantity or quality of food may suffer developmental lags and incur medical problems. In the most serious form of this problem, the child can starve to death.

· Inadequate hygiene - A child who is inadequately bathed may have repeated skin infections or other persistent skin disorders. Severe diaper rash as well as the chronic presence of dirt or feces on the child's skin, under the nails, or on clothing may also indicate inadequate hygiene.

· Medical neglect - a child who does not receive needed medical or dental care, including required medication may develop a health problem, or a pre-existing health problem may be aggravated.

Compelling Reasons for Healthcare Providers to Intervene

The Council on Ethical and Judicial Affairs of the American Medical Association states that the medical ethical principle of beneficence requires physicians to intervene in cases of domestic violence. Bioethicists Edmund Pellegrino and David Thomasama say:

· The aim of medicine is to address not only the bodily assault that disease or an injury inflicts but also the psychological, social, even spiritual dimensions of this assault. To heal is to make whole or sound, to help a person reconvene the powers of the self and return, as far as possible, to his (or her) conceptions of a normal life.

· The ethical principle of non-malfeasance--do no harm--also directs physicians to diagnose domestic violence.

· When a diagnosis of abuse is missed, treatment is likely to be inappropriate and potentially harmful. For instance, diagnosing pain medications or mild tranquilizers these are contraindicated for abuse victims because they are at an increased risk for suicide and drug or alcohol abuse.

· Failing to diagnose abuse may further the victim's sense of entrapment. Inability to find help often causes victims to feel that there is no escape from the violence. Failure to diagnose domestic violence increases the patient's health risks.

· The solutions to domestic violence extend into social, legal and political realms, but the medical profession can provide a number of important interventions. The most important contribution a physician can make to ending the cycle of abuse and protecting the health and welfare of a victim is in identifying and acknowledging the abuse. This simple intervention can initiate the process whereby the victim may seek the necessary assistance to find safety.

· Other important responsibilities of health care professionals include: providing sensitive support, clear documentation of the abuse, providing information about options and resources, making necessary referrals (with the patient’s consent).

Assisting the Victim to Make an Exit Plan

If the patient is not willing to take immediate action to leave the attacker, assist the patient in making an exit plan for use should the need arise. Make sure the patient knows where he or she will go if they need to leave. The victim should have 24-hour access to this location whether it is a shelter, friend’s home, or other place of safety. Gather the following items together in a place where they can be accessed quickly, maker sure, they will not be located by the abuser.

· Identification for yourself and any children. Driver’s license, birth certificates, passports, green cards ect.

· Important Records- Mortgage documents, titles, health records, insurance cards and records, address book, marriage license Copies of court records

· Divorce papers, custody decrees, restraining orders.

· Money, checkbook, bankbook, and credit cards.

· A small supply of medications or a list of the drug and the dosage, along with the name and address of the prescriber.

· Clothing, toys, and comfort items for yourself and any children.

· Sentimental items

· Small, sellable objects

· Extra set of keys to car, home, office, and safety deposit box (Burnett, 2006).

The Cycle of Separation

When the victim decides to leave the abuser, the abuser goes through a set of very predictable behaviors:

Indifference - Initially the abuser will say things like, “go ahead and leave, I don’t care” or “I don’t need you.”

Manipulative Anger - Anger is a tool that abusers use to gain and maintain control. He may claim outrage at not being able to see his children. Abusers, in truth, are no angrier than anyone else. They choose to be angry, because anger is a tool.

Manipulative Courting - The abuser attempts to win the victim back by courting her again. This tool sometimes is very successful. The abuser may make promises to change, such as to quit drinking, gambling, ect. He may remind her of good times that they might have shared. He will not discuss the abuse; he emphasizes past and future good times and says he wants her back.

Defaming the Survivor - In this stage of the separation process, the abuser tells lies about the victim to her family and friends. His goal is to isolate her socially and to diminish her support structure. Often the victim does not know about the lies. The most frequent lie is that the victim was having an affair. This is his attempt to justify his abuse, and maintain his perceived esteem.

Renewal of Manipulative Anger - This is the point of danger in the separation process. The abuser realizes that the victim is not coming back and may attempt to act upon prior threats toward the victim.

Documenting the Abuse in the Medical Record

The medical record is a tool that may result in the conviction of an assailant if the case ever goes to court. Always be sure to:

· Clearly document all finding, interventions, and actions in a legible manner.

· Record what the patient says verbatim enclosing in quotation marks as needed.

· Record a description of the incident as the patient relates it, and history or incidents of abuse. (If the patient is reluctant to speak frankly or it seems they are not telling all the truth document the patient behavior using objective language).

· Include other areas of physical or mental concern that may relate to the abuse.

· Include the name and as much demographic information as possible about the abuser and their relationship to the victim.

· Document injuries as completely and thoroughly as possible noting location, size, shape, color, and apparent age. Also, include anatomical charts and color photographs of the injuries before treatment.

If a patient is being seen for an injury or other symptoms related to an acute battering event, ask in detail about what happened. Record the chief complaint and detail the descriptions of the abuse, including the perpetrator, his or her relationship and the time, date, and location of the abuse. Use the victim's own words in quotes whenever possible. For example, "My husband hit me with a bat" is better than "Patient has been battered." Ask about previous abusive episodes.

If photographs are taken, attach a consent form to the chart and use a Polaroid or digital camera to take the images. One photograph should be a full body shot that includes the victim’s face. This clearly links the injuries to the victim. Include a torso image and close-ups of all bruises and wounds. Include two shots of each injury taken from two different angles with a reference device such as a ruler in the picture to indicate size of the wounds.

On the back of the photograph write the patient name, medical record number, date and time of the photograph, name of the photographer, location, and names and titles of witnesses. The photographer should sign the photograph.

One the back of the photograph indicate the location of the injury and the subjects stated cause of injury. Torn and damaged clothing also may be photographed. Document injuries not clearly indicated by photographs on a body chart. Preserve any damaged clothing, jewelry, or weapons using the chain of evidence protocol.

If the patient has been sexually assaulted, take care to preserve any evidence and follow protocols for examination and collection of specimens (Burnett, 2006).

Assess the victim’s safety for returning home. Are they suicidal or homicidal? Is the victim going to be in danger if they return home? Offer the victim immediate referral to a domestic violence shelter. Are children involved? In some states domestic violence falls under mandated reporting and if a child is injured or in danger mandated reporting is in force in most states. Follow you state’s mandated reporting guidelines.

References

Allen, M.C., (2006). Domestic Violence: The Florida Requirement. Accessed July, 2008 at: http://www.netce.com/coursecontent.php?courseid=362#BEGIN

Allen, M.C., (2007). Domestic Violence. Accessed July 2008 at: http://www.netce.com/coursecontent.php?courseid=450#BEGIN

Allen, M.C., (2008). Domestic Violence: The Kentucky Requirement. Accessed July 2008 at: http://www.netce.com/coursecontent.php?courseid=485#BEGIN

Burnett, Lynn B., Adeler, Jonathan. (2006). Domestic Violence. Accessed July 2008 at: http://www.emedicine.com/emerg/TOPIC153.HTM

Centers for Disease Control. (2006). Fact Sheet : Understanding Intimate Partner Violence Accessed July 2008 at: http://www.cdc.gov/ncipc/dvp/IPV/default.htm

Ganley, A.L., & Warshaw, C. (1995). Improving the Health Care Response to Domestic Violence: A Resource Manual for Health Care Providers. San Francisco: Family Violence Prevention Fund.

Jones, A. (1994). Next time, she'll be dead: Battering and how to stop it. Boston: Beacon

Violence Policy Center. (2005). When Men Murder Women: an Analysis of 2003 Homicide Data. Accessed July, 2008 at: http://www.vpc.org/press/0509wmmw.htm

National Coalition Against Domestic Violence. (2007). Domestic Violence Facts California. Accessed July 2008 at: http://www.ncadv.org/resources/Statistics_170.html

National Coalition Against Domestic Violence. (2007). Domestic Violence Facts Florida. Accessed July 2008 at: http://www.ncadv.org/resources/Statistics_170.html

National Coalition Against Domestic Violence. (2007). Domestic Violence Facts New York. Accessed July 2008 at: http://www.ncadv.org/resources/Statistics_170.html

Nelson, John C., Sherin, Kevin M., (2006). Telltale Signs of Intimate Partner Violence Among Adolescents: Screening, Reporting, and Creating an Exit Plan. Accessed July 2008 at: http://www.medscape.com/viewprogram/6108_pnt

Star, B. (1987). “Domestic Violence.” Encyclopedia of Social Work. Silver Spring: National Association of Social Workers.

Sugg, K., & Inui, T. (1992). Primary Care Physicians' Response to Domestic Violence. Journal of the American Medical Association, 267(23), 3157.