After reading this article, the learner will be able to:
1. Identify personal and social factors associated with the prevalence of domestic violence.
2. State barriers encountered when working with patients who are victims of domestic violence.
3. Discuss how nurses can help victims of human trafficking or domestic violence.
Your patient confides to you that she is afraid to go home because her partner is upset with her for coming in to the office today. How should you respond? What additional questions should you ask? Is this concerning for domestic violence? If so, what do you do? Nurses need to be aware of these possible situations in order to best assist patients. So, what exactly constitutes domestic violence?
Domestic Violence Definition
Many terms are used to describe domestic violence (DV), including intimate partner violence (IPV), family violence and relationship violence. Each state defines domestic violence in statute. Florida 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 family or household member."1
Many forms of domestic violence exist. The one commonality in domestic violence is that it is a choice made about having control over someone. Misperceptions may lead some people to think DV is associated with substance abuse, cultural differences, financial problems, insecurity, or past war experiences. This is not true. While stressful events can trigger a form of violence, domestic violence is about having control over another human being.2
Every 9 seconds in the United States, a person is physically beaten or assaulted.3 Approximately 10 million men and women are abused each year in the United States, and this abuse accounts for 75% of all violent crimes.3 Nineteen percent of DV incidents involve a weapon, and 72% of all murder-suicides involve people who were intimate.
Women between the ages of 18 and 24 are at highest risk for DV.3 Only 34% of victims receive medical care for their physical and emotional issues related to DV.3 In terms of cost to society, $8.3 billion are spent on direct and indirect costs associated with DV.3 Eight million work days are lost to complications from DV.3
Factors Associated with DV
In most cases of DV, the perpetrator desires to have control over others. This phenomenon leads to unhealthy interactions that can affect a single person or an entire family. Some authors suggest that stress can enhance the perpetrator's need for control, and that factors such as unstable finances, substance abuse or inadequate coping skills may lead to violence. Personal risk factors leading to acts of violence include young age; lower educational level; witnessing DV in childhood home; recreational drug use; and presence of a mental health disorder.4 Today's social acceptance of violence is now considered an additional risk factor. Violence is a common occurrence, making many people numb to it. This may explain why people who experience emotional abuse (who do not have physically observed injuries) simply do not report this type of abuse to police or crisis centers.
Because of the personal and social risk factors associated with domestic violence, it is important to educate people about what constitutes a healthy relationship. The Domestic Abuse Intervention Project developed the Equality Wheel to help perpetrators of violence understand how to treat their partners with equality and promote a healthy relationship.5 It also developed the Power and Control Wheel to inform DV victims about tactics abusers use to obtain and maintain control.
The Power and Control Wheel uses female terminology in reference to victims because women are overwhelmingly the targets of domestic violence. The authors suggest that violence by women against men is different in that men use violence against women through learned behaviors, while women's violent acts usually are done to protect them from future violence. The authors stated: "Making the Power and Control Wheel gender neutral would hide the power imbalances in relationships between men and women that reflect power imbalances in society. By naming the power differences, we can more clearly provide advocacy and support for victims, accountability and opportunities for change for offenders, and system and societal changes that end violence against women."5
Women who seek mental health services are more likely to be victims than perpetrators of violence, however, after experiencing violence most of their lives, these women tend to use more violence on others.6 Domestic violence is a common hidden problem among women who receive mental health services and is a major cause of mental ill health globally.6 Interventions that are most appropriate for this group include advocacy, empowerment strategies, psychological therapies, and treatment options for co-morbidities such as depression.6
Co-morbidities that lead to domestic violence can arise as a result of being a victim of domestic violence. These may include a history of alcoholism, mood disorders such as depression or anxiety, and having been a child abuse victim or in an abusive relationship. External stressors that can lead to abusive relationships include lack of social support, inappropriate coping mechanisms, loss of work or income, and poor training on caregiving responsibilities.7
Domestic Violence on Men
Little is written about men as victims of domestic violence. Society tends to ignore or diminish the consequences of this health issue. Men tend not to report domestic violence for various reasons, including embarrassment, feeling they will not be believed, and feeling that nothing will be done. In fact, it has been reported that California judges are 13 times more likely to grant a restraining order against a man than to grant men the same protection/restraining order against female abusers.8 Additionally, police typically allow women victims to stay in their homes during investigations of abuse while making the men leave the home during the investigation.8 This demonstrates inequality to men who are being abused.
Porter8 reported that the media can influence societal views of men as victims of DV. The author wrote that comic strips often depict humorous incidents of men getting beaten by women without many questions; however, jokes are rarely made about women getting abused by men. Men who are abused may be referred to as "henpecked," and this is considered a weakness on their part. It is commonly viewed as psychological or emotional abuse only when it is directed at women. The disparity is also apparent when reviewing incarceration times. Men average 17.5 years of incarceration for the crime of abuse, while women average 6 years of incarceration for the same crime.8
Another problem is what to do with male victims of DV. Few shelters have services appropriate for DV victims who are men. In addition, the terminology surrounding DV resources is basically gender-specific for women, i.e., "battered women" and "women's shelters." Nurses should be aware of this problem and use gender-neutral words in cases of suspected male victimization.
State laws vary on what constitutes "vulnerable groups" in reference to domestic violence. In Florida, children (anyone younger than 18 years or not emancipated) who have been harmed or are suspected to have been harmed must be reported to the Florida Abuse Hotline operated by the state's Department of Children and Families.9 If the child resides out of state but the violence occurred in the state of Florida, the same facts would still be reported. Interestingly, reports of exploitation cannot be accepted post de facto (after the vulnerable victims is deceased).
Signs and Symptoms of DV
DV occurs in physical, sexual, mental and emotional forms. Physical violence tends to get the most attention. A common form of physical violence in DV is strangulation. Up to 69% of domestic violence patients have been strangled or suffocated at least once during their lifetime, and 10% of violent deaths in the U.S. are attributable to strangulation.10 Types of strangulation include throttling (manual pressure), garroting (ligature), hanging or postural strangulation (when the neck is placed over a fixed object). Death can occur quickly when oxygen exchange is compromised.10 Permanent brain damage can occur in 3 minutes or less, while death will occur in 4 to 5 minutes.10
Two forms of domestic violence that are gaining much attention are cyberstalking and human trafficking. Cyberstalking is the use of electronic means to threaten someone. It is often difficult to track the perpetrator, since he or she often uses multiple websites or various names and passwords to protect his or her identity. Examples of cyberstalking may include making/sending threatening phone calls or text messages, sending pornographic material via the web to people at their homes or at work, making unwanted advances on social media platforms, posting improper messages in a chat room, or pretending to be the victim and making improper remarks or posting items the victim would never say or do.11
Human trafficking involves many areas, including sex trafficking, child sex trafficking, forced labor, bonded labor, domestic servitude, forced child labor, and unlawful recruitment and use of child soldiers. A higher prevalence of human trafficking occurs in industries that employ unskilled or low-skilled laborers who are often undervalued for their work contributions.12
In 2015, 407 cases of human trafficking were reported in Florida. The majority of these cases involved women (n = 348) involved in sex trafficking (n = 302).12 But this problem exists worldwide, and it mandates attention. Governments across the world are working to establish laws that reflect respect for human life, incorporate fair labor practices, and punish those who are guilty of these crimes. In 2010, the International Labor Organization estimated human trafficking to be a $32 billion crime.12 Dorydaitis13 wrote that human trafficking is the third largest source of income for organized crime, and that twice as many people are enslaved today as during the African slave trade.13
Additional resources are needed to help victims feel secure about their future, including: housing arrangements, financial resources, education and healthcare. Nurses are in a pivotal role to help these victims. Learning how to recognize these victims, demonstrating empathy and caring communication, and knowing what community resources are available are essential for nurses. Nurses require knowledge about the recognition and treatment of human trafficking; the medical and mental issues that may occur (i.e., sexually transmitted infections); how to collect evidence if needed; resources available for victims; and how to be an advocate for patients who are victims. Every nurse should be prepared to share their state's abuse reporting phone number.
Adverse Effects of Domestic Violence
A multitude of medical symptoms associated with domestic violence include but are not limited to: musculoskeletal problems (including fractured bones), gastrointestinal issues, neurological symptoms or disorders, mental health problems, cardiovascular concerns, and substance abuse.14 Research demonstrates that actions taken by survivors to achieve safety may also produce a wide range of negative health concerns, including financial stressors, unstable living conditions, custody battles for children, and escalated violence episodes.4,14
Many tools are available to screen for domestic violence. One easy-to-use screening tool is the HITS tool. This tool contains four questions that utilize a 5-point Likert answer scale. The HITS tool has a sensitivity of 30% to 100% (30% with men) and a specificity of 86% to 99%.15 The following are questions utilized on the HITS tool:
1. Does he or she physically Hurt you?
2. Does he or she Insult you or talk down to you?
3. Does he or she Threaten you with harm?
4. Does he or she Scream or curse at you?
Another screening tool is the SAFE survey.2 It helps providers remember to screen and assist patients involved in a domestic violence relationship or environment.
· S = screen all patients
· A = assess current safety
· F = facilitate referrals
· E = educate/empower.
Abuse victims don't want their abusers to know they are receiving help or assistance. Therefore, nurses should provide advice about how to keep such actions secret. For example, after placing a call for information about domestic violence, the victim should hang up and dial some other number to prevent the abuser from hitting redial to find out what number was called. When available, victims should use a public computer to gain information on community resources, rather than a home computer the abuser will likely monitor. If the victim uses a personal computer, he or she should always delete the browsing history.
Nurses should also advise victims to talk with friends and family on a regular basis about general topics so that communication with them doesn't seem out of the ordinary to the abuser. The victim should establish a code word he or she uses to alert those friends and family when the victim may be in trouble or feel threatened. DV victims should develop a safety plan or escape plan, or have a safe room (an area where potential weapons are not available such as a kitchen) to hide in until help arrives.
After a victim has left an abusive relationship, he or she needs to be cautious and on guard for any suspicious behavior. Victims are at highest risk for homicide during this time. Actions that can help maintain safety are changing phone numbers and locks; recording any threats received; taking different routes to work; avoiding staying alone; and asking for help as needed.16
Make a Commitment
Domestic violence is a national healthcare issue, and it impacts nurses regardless of where they work. Understanding DV risk factors and early recognition of sequelae in victims is essential. Nurses need to be comfortable talking with patients about domestic violence and have knowledge of resources available for this group's needs. All nurses must make a commitment to improve the health of patients and be alert to early recognition of DV.
1. 2015 Florida Statutes. Domestic Relations. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0741/Sections/0741.28.html
2. Americans Overseas Domestic Violence Crisis Center. Domestic Violence 101. http://www.866uswomen.org/Domestic-Violence-101.aspx
3. National Coalition Against Domestic Violence. What is Domestic Violence? http://ncadv.org/learn-more/what-is-domestic-violence 4. World Health Organization. Understanding and Addressing Violence Against Women. Intimate Partner Violence. http://apps.who.int/iris/bitstream/10665/77432/1/WHO_RHR_12.36_eng.pdf
5. Domestic Abuse Intervention Programs. Wheel gallery. http://www.theduluthmodel.org/training/wheels.html
6. Hegarty K. Domestic violence: The hidden epidemic associated with mental illness. Brit J Psychiatry. 2011;198(3):169-170.
7. United States Preventive Services Task Force. Screening Women for Intimate Partner Violence and Elderly and Vulnerable Adults for Abuse: Systematic Review to Update the 2004 U.S. Preventive Services Task Service Task Force Recommendations. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening
8. Porter T. Hit Like a Girl: Women Who Batter Their Partners. http://www.inter-disciplinary.net/wp-content/uploads/2011/04/porterepaper.pdf
9. Florida Department of Children and Families. Florida Abuse Hotline 2013. Reporting Abuse of Children and Vulnerable Adults. http://www.dcf.state.fl.us/programs/abuse/publications/mandatedreporters.pdf
10. Carlson S. Strangulation-asphyxia and terror. Canad J Emerg Nurs. 2014;37(2):20-23.
11. US Department and Health and Human Services. Office on Women's Health. Violence against women: Stalking. http://www.womenshealth.gov/violence-against-women/types-of-violence/stalking.html
12. National Human Trafficking Resource Center. Data Breakdown. https://traffickingresourcecenter.org/sites/default/files/NHTRC%202015%20Florida%20State%20Report%20-%20FL%20-%2001.01.15%20-%2012.31.15.pdf
13. Dorydaitis T. Human trafficking: The role of the healthcare provider. J Midwif Women's Health. 2010;55(5):462-467.
14. Alejo K. Long-term physical and mental health effects of domestic violence. Themis. 2014;2(1):80-98.
15. Rabin R, et al. Intimate partner violence screening tools. Am J Prev Med. 2009;36(5):439-445.
16. Americans Overseas Domestic Violence Crisis Center. Staying Safe. http://www.866uswomen.org/Staying-Safe.aspx?link=safe
Marquetta Flaugher is a dually certified family and psychiatric-mental health nurse practitioner. She practices in the sleep disorders clinic at Bay Pines Veterans Affairs Medical Center and is a member of the adjunct nursing faculty at the University of South Florida in Tampa, Fla., and Southern New Hampshire University in Manchester, NH. She has completed a disclosure statement and reports no relationships related to this article.