#97914: Domestic Violence: The Kentucky Requirement

Because a gynecologist or obstetrician is frequently a woman's primary care physician, these healthcare providers should be particularly sensitive to domestic violence issues [15]. According to the CDC, IPV affects as many as 324,000 pregnant women each year[16]. This represents approximately 8% of all pregnant women in the United States. As with all domestic violence statistics, this number is presumed to be lower than the actual incidence as a result of under-reporting and lack of data on women whose pregnancies ended in fetal or maternal death. This makes IPV more prevalent among pregnant women than some of the health conditions included in prenatal screenings, including pre-eclampsia and gestational diabetes[16]. Because 96% of pregnant women receive prenatal care, this is an optimal time to screen for domestic violence and develop trusting relationships with the women. Possible factors that may predispose pregnant women to IPV include young maternal age, unintended pregnancy, delayed prenatal care, lack of social support, and use of tobacco, alcohol, or illegal drugs[16,17].

The overarching problem of violence against women cannot be ignored, especially as both mother and unborn child are at risk. One study found that pregnant women who had been treated at a hospital after a violent incidence had an eight-fold increased risk of fetal death[69]. At this particularly vulnerable time in a woman's life, an organized clinical construct leading to immediate diagnosis and medical intervention will ensure that therapeutic opportunities are available to the pregnant woman and will reduce the potential negative outcomes[18,19]. Healthcare professionals should also be aware of the possible psychologic consequences of abuse during pregnancy. There is a higher risk of stress, depression, and addiction to alcohol and drugs in abused women, and victims/survivors are less likely to obtain prenatal care and to develop postpartum depression[20,69,70].

The United States is becoming increasingly diverse in terms of ethnic composition. By 2044, the U.S. will become a majority-minority nation [71]. In 2021, 13.6% of the U.S. population was foreign-born, most of whom reside in the West[72]. It is inevitable, therefore, that race, culture, and ethnicity will have a profound effect on American culture. Consequently, health professionals must become more aware of, and sensitive to, the cultural norms, belief systems, and needs of culturally diverse patients in order to provide relevant services and interventions. Results from the National Violence Against Women Survey indicate that all racial minorities in the United States experience more IPV than white Americans, with the exception of Asian Americans[22]. It has been suggested that ethnic minority groups may be more vulnerable to violence as a result of environmental risk factors such as poverty, racism, oppression, and discrimination. For example, one study suggests that nearly one-third of African American women experience IPV in their lifetimes, compared with one-fourth of white American women[22]. Another study with 1,155 Mexican American women found that 10.7% of the sample reported physical abuse by a current partner. Researchers found that those born in the United States reported a rate of violence higher than those born in Mexico[23]. In a qualitative study of 10 Mexican women who experienced IPV, immigration status (specifically the fear of deportation) was the primary reason they did not leave the relationship or seek help[73].

In the Asian American community, the mistaken notion that Asian Americans have achieved success often cloaks the issue of domestic violence. In a telephone interview with 336 Asian American women in the San Francisco and Los Angeles areas, 27% experienced emotional abuse by an intimate partner, 16% reported being pressured to have sex without their consent, and 12% reported that an intimate partner had hurt or had attempted to hurt them by means of hitting, kicking, slapping, shoving, object throwing, or threatening their lives with a weapon[24]. Research indicates that perpetrators in these cases are overwhelmingly male[74]. Although this is a small study, it does indicate that domestic abuse is an issue for some Asian Americans.

Culture, race, and ethnicity also influence help-seeking patterns. Help-seeking behavior is in part influenced by an individual's definition and understanding of abuse, which is ultimately influenced by culture. For example, an ethnic minority woman who is being abused by her husband may not seek help if she does not label the event as a problem. Instead, she may believe the abuse is something to be persevered. Financial limitations, suspiciousness or wariness of health or mental health professionals, limited English proficiency, and inconvenience in locating and traveling to agencies are also hindrances specific to these populations[25].

Children who are raised in violent homes are also in danger. These children are at high risk for abuse and for emotional damage that may affect them as they grow older. Slightly more than half of female victims/survivors of domestic violence live in a household with at least one child younger than 12 years of age, and between 3.3 million and 10 million children witness domestic violence annually [24,26]. Studies demonstrate that children who witness domestic violence are more likely to grow into a perpetrator or victim of domestic violence than a child who was himself or herself abused, thereby creating a cycle of violence. For example, in one study, adolescent witnesses of abuse were also more likely to report having perpetrated abuse (42%) compared to non-witnesses (15%)[27]. Research regarding the psychosocial outcomes of children exposed to domestic violence has found that child witnesses exhibit more aggression, anxiety, difficulties with peers, and academic problems than the average child[26,28]. An estimated 47% of children who have witnessed IPV at home are younger than 6 years of age, and these preschool-age children are more likely to show evidence of internalizing behavior problems (e.g., anxiety, depression, somatic complaints) compared to older children, who show more signs of externalizing behavior problems (e.g., bullying, aggression, misconduct)[29]. In addition to witnessing violence, these children may also become direct victims/survivors of violence, as child maltreatment occurs in 30% to 60% of families in which IPV is reported[30]. Moreover, statistics demonstrate that 85% of domestic violence victims/survivors abuse or neglect their children.

Indirect exposure to violence may also have consequences. In one study, children whose mothers were victims/survivors of IPV exhibited externalizing problems regardless of whether they directly witnessed the violence[75]. The researchers concluded that the children may sense and internalize their mothers' psychologic distress[75].

Adolescents are also victimized. Between 7% and 17.5% of all homicides against girls 12 to 17 years of age are committed by an intimate partner[31,12]. Among young women 18 to 24 years of age, the rate is 42.9%. Abused teens often do not report the abuse. Individuals 12 to 19 years of age report only 35.7% of crimes against them, compared to 54% in older age groups[32]. Accordingly, healthcare professionals who see young children and adolescents in their practice must have the tools necessary to detect these "silent victims" of domestic violence and to intervene quickly to protect young children and adolescents from further abuse.

Adverse childhood experiences (including domestic violence) contribute to lifelong negative emotional, physical, and behavioral consequences. These adverse childhood experiences appear to be dose-related, in that the more traumatic the childhood experiences, the more severe the outcomes will be in later life[76]. In addition, if the stressors endure over a long period of time (referred to as "toxic stress"), it can lead to negative changes to the brain[76].

Abused and neglected elders, who may be mistreated by their spouses, partners, children, and other relatives, are among the most isolated of all victims/survivors of family violence. Among the elderly, it is estimated that 1 in 10 individuals will experience at least one form of abuse (e.g., physical, psychologic, financial, sexual, neglect) [34]. Those 65 years of age and older are projected to number 83.7 million in the United States by 2050, almost double the number in 2012, exponentially increasing the number of individuals experiencing elder abuse[34].

Because elder abuse can occur in family homes, nursing homes, board and care facilities, and even medical facilities, healthcare professionals must remain keenly aware of the potential for abuse. When abuse occurs between elder partners, it is primarily manifested in one of two ways, either as a long-standing pattern of marital violence, or as abuse originating in old age. In the latter case, abuse may be precipitated by issues related to advanced age, including the stress that accompanies disability and changing family relationships.

It is important to understand that the domestic violence dynamic involves not only a victim but a perpetrator as well. For example, an adult son or daughter who lives in the parents' home and depends on the parents for financial support may be in a position to inflict abuse. This abuse may not always manifest itself as violence, but can lead to an environment in which the elder parent is controlled and isolated. The elder may be hesitant to seek help because the abuser's absence from the home may leave the elder without a caregiver. Because these elderly victims/survivors are often isolated, dependent, infirm, or mentally impaired, it is easy for the abuse to remain undetected[77]. Healthcare professionals in all settings must remain aware of the potential for abuse and keep a watchful eye on this growing and particularly vulnerable group.

Statistics confirm that domestic violence is predominantly perpetrated by men against women; however, there is evidence to suggest that women also exhibit violent behavior against their male partners [35]. Studies demonstrate that approximately 5% of murdered men are killed by intimate partners[31]. It is persuasively argued that the impact on the health of female victims/survivors of domestic violence is generally much more severe than the impact on the health of male victims/survivors[36]. However, approximately 7% of men are raped and/or physically assaulted by an intimate partner in their lifetime[3,24]. In 2008, men experienced 101,000 nonfatal violent victimizations by an intimate partner[37]. Healthcare professionals should always keep in mind that men can also be victimized and experience mental health consequences of the abuse. Because IPV is perceived as a "woman's issue," men who are victims/survivors of IPV may perceive the experience as a threat to their manhood[78].

Domestic violence exists in the gay, lesbian, bisexual, transgender, and other gender and sexual minorities (LGBT+) community, with the 2010 National Intimate Partner and Sexual Violence Survey indicating that 43.8% of lesbian women, 61.1% of bisexual women, 26% of gay men, and 37.3% of bisexual men reporting ever having experienced rape, physical violence, and/or stalking by an intimate partner [38]. The lifetime prevalence rate of psychologic abuse was 59% for gay men and 53% for bisexual men[38]. Men living with male intimate partners experience significantly more IPV than men who live with female intimate partners[4]. This supports other statistics indicating that IPV is perpetrated primarily by men. Three dominant barriers to help-seeking by LGBT+ victims/survivors have been identified: lack of understanding of the problem, stigma, and systemic inequities[80]. In general, much of the IPV literature and knowledge base has focused on heterosexual women's experiences with IPV. Furthermore, because of the stigma of being gay, victims/survivors may be reticent to report abuse and afraid that their sexual orientation will be revealed. Many in this community feel that support services are not available to them due to prejudices of the service providers. Unfortunately, this results in the victim/survivor feeling isolated and unsupported. Healthcare professionals should strive to be sensitive and supportive when working with homosexual patients.

As with domestic violence in the civilian population, military victims/survivors face a host of barriers in disclosing abuse. In addition to shame and embarrassment, fear of reprisals, feelings of isolation, and lack of available services, many military victims/survivors found when they did report abuse, military personnel were not sensitive to their needs [39]. Given these barriers to disclosure, it is difficult to assess the prevalence of domestic violence among military families. According to the U.S. Department of Defense, there were a total of 18,208 reported incidents of domestic abuse in 2009[40]. However, it should be noted that a 2010 report released by the U.S. General Accounting Office (GAO) indicated that the U.S. Department of Defense's use of multiple registries and inclusion of only those reports made to the Family Advocacy Program (excluding cases handled by civilian law enforcement, identified by nonmilitary medical staff, and reported to commanders) make calculating the actual number of domestic violence cases impossible[40]. Reports from the Congressional Research Service indicate that among the active-duty population, there were 16,912 reported incidents of spouse and intimate partner abuse in 2018[33]. Among these, 8,039 reports (6,372 victims/survivors) met the Department of Defense definitions. Physical abuse accounted for the highest number of reports (73.7%), followed by emotional abuse (22.6%), sexual abuse (3.6%), and neglect (0.06%)[33].

The Family Advocacy Program is responsible for seeing that victims/survivors remain safe and have access to support and advocacy services and that offenders receive appropriate intervention services[41]. The Program works to prevent domestic abuse by educating service members and families about the issue; identifying families experiencing domestic abuse; providing support services to victims/survivors of abuse; and providing treatment for abusers.

Risk factors among this group are complex and multifaceted. Brewster conducted a study of 2,991 abusers who used physical domestic violence that received treatment at the Air Force Family Advocacy Program and agreed to participate in the study. As with the general population, the physical violence sustained was more severe when the offender was male. However, previously reported domestic violence cases were higher than the base rate for the general population—one in four had been reported for spouse abuse, and one in eight offenders had been substantiated for spouse abuse[42].

Presence of a psychiatric disorder can also increase the risk of domestic violence in military families. In one systematic review, 27.5% of male veterans with PTSD disclosed to perpetrating physical violence in the last year, and 91% reported using psychologic violence against their partner[81]. Male members of the military with depression had a 3.95 increased likelihood of perpetrating physical violence against their partner compared to men without a mental disorder[81].

It has also been speculated that deployment, exposure to the trauma of combat, and the development of post-traumatic stress symptoms provokes military veterans to be violent at home[43,44]. Furthermore, when these veterans do obtain treatment, either voluntarily or as mandated, many do not complete their treatment regimens.

Kentucky law mandates the reporting of the abuse or neglect of children and elderly and/or vulnerable adults (i.e., those with a physical or mental disability) to the Cabinet for Health and Family Services, the state or local police, and/or the local prosecutor's office [58,60]. However, as of June 2017, Kentucky's law mandating reporting of suspected domestic or dating violence changed to a mandatory information and referral position[85].

According to the revised statute, if a professional has reasonable cause to believe that a person has experienced domestic violence or dating violence, the professional shall provide the individual with information about the regional domestic violence program or rape crisis center and information on how to access protective orders[86]. This is limited to persons with whom the professional has a professional interaction (as opposed to any contact whatsoever). In addition, a professional may report to a law enforcement agency at the request of a victim/survivor, but a report should not be made if the individual objects[86].

If a healthcare professional knowingly and willfully fails to report a case of suspected child or elder abuse as mandated by the law, then he or she can be subject to criminal penalties[58]. In fact, a healthcare professional who reports a suspected case of abuse in good faith in accordance with these laws is protected from civil and criminal liability[59].

During the assessment process, a practitioner must be open and sensitive to the client's/patient's worldview, cultural belief systems, and how he/she views the injury [61]. This may reduce the tendency to over-pathologize or minimize health concerns of ethnic minority patients. Pachter proposed a dynamic model that involves several tiers and transactions[62]. The first component of Pachter's model calls for the practitioner to take responsibility for cultural awareness and knowledge. Professionals must be willing to acknowledge that they do not possess enough or adequate knowledge in health beliefs and practices among the different ethnic and cultural groups they come in contact with. Reading and becoming familiar with medical anthropology is a good first step.

The second component emphasizes the need for specifically tailored assessment[62]. Pachter advocates the notion that there is tremendous diversity within groups. For example, one cannot automatically assume that a Chinese immigrant adheres to traditional beliefs. Often, there are many variables, such as level of acculturation, age at immigration, educational level, and socioeconomic status, that influence health ideologies. Finally, the third component involves a negotiation process between the client/patient and the professional[62]. The negotiation consists of a dialogue that involves a genuine respect of beliefs. It is important to remember that these beliefs may affect symptoms or appropriate interventions in the case of domestic violence.

Culturally sensitive assessment involves a dynamic framework whereby the practitioner engages in a continual process of questioning. These components are meant to provide an introduction to help practitioners recognize the range of dimensions, including physical, biologic, social, and cultural factors, that affect immigrants and ethnic minorities. By incorporating cultural sensitivity into the assessment of individuals with a history of being victims/survivors or perpetrators of domestic violence, it may be possible to intervene and offer treatment more effectively.

All practitioners who deal with domestic violence should periodically review safety planning with victims/survivors. Homicide is of high risk for victims/survivors; therefore, safety planning is crucial. When advocating a safety plan, it is important to:

Although safety planning may be advocated, it does not necessarily mean victims/survivors will employ safety planning guidelines.

It is important to note that general safety planning does not take into account the specific needs of victims/survivors who fall into vulnerable populations or affected children [87]. Because these individuals are at higher risk of marginalization and oppression, they may feel powerless to execute a safety plan. It is important for practitioners to assess each IPV victim/survivor and his/her readiness to change, circumstances, resources, and needs in order to tailor a specific safety plan[88].

If a victim/survivor requires or requests legal assistance, local spousal abuse centers will be able to assist in making the appropriate referral. For the purposes of this course, it is important for healthcare professionals to know that domestic violence victims/survivors in Kentucky have legal remedies available to them. The first form of legal protection is an emergency protective order, which can be filed and heard by a judge without the batterer being informed of the filing or of the hearing. In cases of dating violence and stalking/sexual assault cases, a temporary interpersonal protective order can be filed [79]. Protective orders can be filed at the Office of Circuit Court Clerk in the county of residence (or temporary residence). Each county's contact information is available athttps://courts.ky.gov/courts/clerks [79].

The batterer will not be present at the hearing, and the victim/survivor can present his or her evidence unopposed. This is referred to in the legal community as an ex parte hearing. The associated forms are relatively simple to file, and an attorney is not required. Having an attorney present, however, may result in obtaining a more thorough order. If the victim/survivor is not represented by an attorney, it is important that a battered woman's advocate, often called a legal advocate, be located to accompany the individual to court. To find an advocate trained in domestic violence issues, healthcare professionals may contact a local domestic violence center. The most ideal representation and assistance in these circumstances is usually a team approach that draws upon the expertise of an attorney and a domestic violence advocate/counselor[63].

Kentucky law provides that a judge can enter an emergency protective order or a domestic violence order that[64]:

The judge is not restricted to only these remedies, but can enter other orders he or she believes will be of assistance in eliminating future acts of domestic violence and abuse. The emergency protective order will be effective for a fixed period of time, as noted in the order, not to exceed 14 days. A copy of this order will be served upon the batterer, and if he or she violates any condition of the order, criminal penalties may be levied [65].

The court reviews petitions for protective orders on filing and schedules an evidentiary hearing within 14 days, at which the batterer is given notice of the hearing and is allowed to attend and present witnesses. If the court finds that a protective order is warranted, a domestic violence order will be followed to restrain the batterer from having contact with the victim/survivor[66]. In a domestic violence order, the protection is effective for up to three years, at which time it can be reissued. Batterers who violate the conditions of the protective order are subject to criminal penalties, including incarceration.

If a batterer violates the terms of the protective order, the police should be contacted immediately. When the police arrive, the victim/survivor should show the police the order or inform the officers of its existence. In Kentucky, a police officer who witnesses the batterer violating the terms of the protective order is required to arrest him or her[67]. If the batterer is no longer present when the police arrive, the victim/survivor should request that a report of the violation, and of any other crimes, be written. The victim/survivor can then follow-up on the violation by contacting the prosecutor's office and ask that an arrest warrant be issued based on the violation[63]. If the county has a Global Positioning System (GPS) monitoring service, the victim/survivor can request the court to order the batterer to wear a GPS device by filing a motion form, which will be evaluated by a judge[79].

If an arrest is made for a misdemeanor, such as violating a protection order, offenders may simply be given a citation and released. If a batterer is arrested and taken into custody, he or she may be released within a few hours. It is important, therefore, to advise victims/survivors to use this time to gather their children and personal belongings, to find a safe place to stay, to begin the process of obtaining a protection order if they do not have one, and/or to seek out a domestic violence program[63]. Victims/survivors should be fully informed about the criminal justice process, their role in it, and the possible outcomes of a criminal case so they can decide whether to turn to the criminal justice system for assistance.

If the prosecuting attorney decides to pursue a criminal complaint, there will be an arraignment. During the arraignment, the court informs the batterer of the charges and ensures that he or she has legal representation. Victims/survivors may be called to testify at an evidentiary hearing or at trial. If a victim/survivor does not want to testify, a court may issue a subpoena ordering him or her to testify; noncompliance with such a subpoena is a violation of law. Most cases are resolved before trial; if the case proceeds to trial, however, victims/survivors are again required to testify[63]. If the batterer is convicted, a judge will sentence him or her to one or any combination of the following: a fine; imprisonment; probation; victim/survivor restitution; mandatory counseling; mediation; substance-abuse treatment; or public service[63].