|
| A) | Sexual abuse | ||
| B) | Verbal abuse | ||
| C) | Physical abuse | ||
| D) | Economic abuse |
DOMESTIC VIOLENCE BEHAVIORS
| Physical Abuse | Psychologic/Verbal Abuse | Sexual Abuse | Financial/Economic Abuse |
|---|---|---|---|
| Kicking, punching, biting, slapping, strangling, choking, abandoning in unsafe places, burning with cigarettes, throwing acid, throwing objects, refusing to help when sick, stabbing, shooting | Intimidation, humiliation, put-downs, ridiculing, control of victim's movement/relationship/behaviors, stalking, threats, threatening to hurt victim's family and children, social isolation, ignoring needs or complaints | Rape, forms of sexual assault (such as forced masturbation, fellatio, or oral coitus), sexual humiliation, unwanted touching, perpetrator refuses to use contraceptives, coerced abortion | Withholding of money, refuse to allow victim to open bank account, all property is in the perpetrator's name, victim is not allowed to work |
| A) | Has your partner ever refused to pay for your contraception? | ||
| B) | Has your partner ever tried to get you pregnant when you did not want to be pregnant? | ||
| C) | Are you worried your partner will hurt you if you do not do what he wants with the pregnancy? | ||
| D) | Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms? |
According to the American College of Obstetricians and Gynecologists (ACOG), interventions that focused on awareness of reproductive and sexual coercion and provided harm-reduction strategies reduced pregnancy coercion by 71% among women who experienced IPV [6]. The ACOG recommends the following screening questions:
Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?
Has your partner ever tried to get you pregnant when you did not want to be pregnant?
Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?
Does your partner support your decision about when or if you want to become pregnant?
| A) | bipolar disorder. | ||
| B) | agitated depression. | ||
| C) | paranoid schizophrenia. | ||
| D) | post-traumatic stress disorder. |
It is imperative that healthcare professionals work together to establish specific guidelines that will facilitate identification of batterers and their victims. In a 2016 study of 288 healthcare facilities in Florida, 78% understood the importance of IPV screening and had some type of IPV screening policy institute in their setting [7]. However, many of the respondents did not know which screening tool was used or the types of screening questions asked. These guidelines should review appropriate interview techniques and should also include the utilization of screening tools, such as intake questionnaires. The following is a review of certain signs and symptoms that may indicate the presence of abuse. Although victims of domestic violence do not display typical signs and symptoms when they present to healthcare providers, there are certain cues that may be attributable to abuse. The obvious cues are the physical ones. Injuries range from bruises, cuts, black eyes, concussions, broken bones, and miscarriages to permanent injuries such as damage to joints, partial loss of hearing or vision, and scars from burns, bites, or knife wounds. In addition to physical signs and symptoms, domestic violence victims also exhibit psychologic cues that resemble an agitated depression. If the perpetrator is present with the victim during an assessment, they may attempt to control the situation; this may manifest as an unwillingness to leave the victim alone or answering questions for the victim.
| A) | Insomnia | ||
| B) | Loss of appetite | ||
| C) | Unexplained euphoria | ||
| D) | Overwhelming guilt and depression |
As a result of prolonged stress, victims often manifest various psychosomatic symptoms that generally lack an organic basis. For example, they may complain of backaches, headaches/migraines, and gastrointestinal problems. Often, they will complain of chronic pain, fatigue, restlessness, insomnia, or loss of appetite. Research indicates that women with a history of intimate partner violence are at greater risk of developing fibromyalgia and chronicfatiguesyndrome [129]. Sleep disturbances, including truncated sleep, nightmares, and restless sleep, are also common [130]. The likelihood of having some sort of stress-related sleep disturbance is 1.24 times greater for women affected by physical intimate partner violence and 3.44 times greater for victims of sexual abuse [130]. Great amounts of anxiety, guilt, and depression or dysphoria are also typical [11,12]. In many women, this constellation of symptoms has been labeled "battered women's syndrome."
| A) | Bodily injury commonly takes the form of bruises and abrasions. | ||
| B) | Bodily injury is much less common than injuries to the genital region. | ||
| C) | Signs of injury are more common with assaults that occur outdoors. | ||
| D) | Signs of injury are more likely to be present in victims examined within 72 hours of the assault. |
Non-genital bodily injury is seen in more than half of all rape victims presenting to emergency departments [15,16]. In one study of 162 women examined between 2002 and 2006, signs of bodily injury were found in 61% of patients, with genital injury present in 39% [17]. Most common were bruises (56%) and abrasions (41%), followed by lacerations, penetrating injury, and bites. Evidence of injury was higher in the 137 cases examined within 72 hours of assault (66% vs. 33%) and in cases in which the assaults occurred outdoors (79% vs. 52%).
| A) | Cases involving nonconsensual sexual intercourse had higher rates of genital tears. | ||
| B) | The absence of signs of genital injury effectively "rules out" sexual assault. | ||
| C) | Abrasions and tears (lacerations) are commonly found at the posterior fourchette and perianal areas. | ||
| D) | When colposcopy is combined with clinical examination, the rate of observed genital injury is about 70%. |
Signs of genital traumatic injury are not always found after sexual assault, and in such cases should not be taken as evidence that sexual assault did not occur [17]. When routine inspection is combined with additional examination techniques, such as colposcopy and toluidine blue staining, the rate for identifying genital injury approaches 70% [18]. A 2021 study compared 834 women, half of whom reported nonconsensual intercourse. External genital tears were found more often in the nonconsensual group [131]. Similarly, anal penetration and tears were also more common in the nonconsensual intercourse group. As such, these may be indicators of lack of consent.
The common types and location of genital injuries, and thus the areas to be examined most closely, are:
Bruises and abrasions to the labia, fossa navicularis, or perianal area
Ecchymoses, tears, or lacerations of the hymen
Abrasions and/or tears of the posterior fourchette
Tears/lacerations in the perianal area
| A) | Zika virus | ||
| B) | Gonorrhea | ||
| C) | Chlamydia | ||
| D) | Bacterial vaginitis |
The infections commonly reported in women after sexual assault are Chlamydia, gonorrhea, trichomoniasis, bacterial vaginitis, and pelvic inflammatory disease (PID) [28]. The possible exposure to hepatitis B virus and human immunodeficiency virus (HIV) is also an important consideration. In general, the risk of infection is relatively low; published estimates are 3% to 16% for chlamydia, 7% for trichomoniasis, and 11% for PID [29]. The risk, however, does vary directly with the degree of genital trauma, associated bleeding (sustained by the victim or assailant), and the number of assailants. The CDC has published guidelines for the assessment, counseling, and preventive treatment of infection following sexual assault, including common pelvic infections, hepatitis B, human papillomavirus (HPV), and HIV [28].
| A) | fetal death. | ||
| B) | postpartum depression. | ||
| C) | addiction to alcohol and drugs. | ||
| D) | All of the above |
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 incident had an eight-fold increased risk of fetal death [33]. 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 [11,34]. 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 are less likely to obtain prenatal care and to develop postpartum depression [33,35,36].
| A) | 330,000 | ||
| B) | 2.3 million | ||
| C) | 10 million | ||
| D) | 46 million |
Children exposed to family violence are at high risk for abuse and for emotional damage that may affect them as they grow older. The Department of Justice estimates that of the 76 million children in the United States, 46 million will be exposed to some type of violence during their childhood [12]. Results of the National Survey of Children's Exposure to Violence indicated that 11% of children were exposed to IPV at home within the last year, and as many as 26% of children were exposed to at least one form of family violence during their lifetimes [41]. Of those children exposed to IPV, 90% were direct eyewitnesses of the violence; the remaining children were exposed by either hearing the violence or seeing or being told about injuries [41].
| A) | Because elderly victims are often isolated, it is easy for the abuse to remain undetected. | ||
| B) | An abusive caregiver may live in the home and depend on the victim for financial support. | ||
| C) | The elder may be hesitant to seek help because the abuser's absence from the home may leave the elder without a caregiver. | ||
| D) | All of the above |
It is important to understand that the needs of older patients will increase, as will the numbers of elder victims of domestic violence. Because elder abuse can occur in family homes, nursing homes, board and care facilities, and even medical facilities, healthcare professionals should 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 [55].
| A) | They are less likely to be believed when they make reports. | ||
| B) | They are less likely to be assaulted than those without disabilities. | ||
| C) | There is a lack of coordinated community service and supports in place. | ||
| D) | Police and prosecutors are reluctant to take cases because they are difficult to win in court. |
Although persons with disabilities are more likely to be victimized, it can be difficult for them to seek and obtain help. Legal action was taken in only 13.6% of cases [67]. Differently able individuals may be less likely to be believed when they report abuse or may be unable to effectively communicate their experiences [69]. Police and prosecutors are often reluctant to take these cases because they are difficult to win in court [68]. In addition, there is a lack of coordinated community services and supports for disabled survivors of sexual assault [67].
| A) | less likely to be economically abused. | ||
| B) | less likely to have healthcare visits. | ||
| C) | less able to leave. | ||
| D) | less likely to return to the relationship. |
As with most sociodemographic risk factors for domestic and sexual violence, the correlation between lower socioeconomic status and violence is potentially bidirectional. Economic abuse (considered a form of intimate partner violence) may precede more severe forms of physical and sexual violence. Women who are financially dependent on their abusers are less able to leave and more likely to return to an abusive relationship, particularly if they are financially dependent on their abusers [79,152]. Greater economic dependence is associated with more severe abuse and homicide by an intimate partner [153].
Financial instability is also a potential adverse effect of intimate partner violence. Current or past exposure to violence has been found to negatively affect ability to sustain stable employment, and women in abusive relationships frequently lose their jobs, experience high job turnover, are forced to quit, or are fired [80].
Victims of sexual violence also experience short- and long-term economic consequences, and low-income individuals are more vulnerable. Victims exceed non-victims in the average number and cost of medical care visits. Beyond medical costs, there are productivity costs and other long-term costs to victims and their families such as pain and suffering, trauma, disability, and risk of death. Sexual violence and the trauma resulting from it can have an impact on the survivor's employment in terms of time off from work, diminished performance, job loss, or being unable to work. These impacts disrupt earning power and have a long-term effect on the economic well-being of survivors [81].
| A) | Rural women live 20 times further from their nearest IPV resource than urban women. | ||
| B) | Intimate partner homicide rates may be lower in rural areas than in urban or suburban locales. | ||
| C) | Substance use disorders and unemployment are less common among IPV perpetrators in rural areas. | ||
| D) | IPV in rural areas may be more chronic and severe and may result in worse psychosocial and physical health outcomes. |
A large national study found that lifetime intimate partner violence victimization rates in rural areas (26.7% in women, 15.5% in men) are similar to the prevalence found among men and women in non-rural areas [82]. There is some evidence that intimate partner homicide rates may be higher in rural areas than in urban or suburban locales [83,153].
Substance use disorders and unemployment are more common among IPV perpetrators in rural areas [83]. It has been suggested that IPV in rural areas may be more chronic and severe and may result in worse psychosocial and physical health outcomes. Poverty in rural areas is also associated with an increased risk for IPV victimization and perpetration for both men and women [84]. Residents of rural areas are less likely to support government involvement in IPV prevention and intervention than urban residents [83].
Although the rates are similar, the risk factors, effects, and needs of rural victims are unique. For example, research indicates that rural women live three times further from their nearest IPV resource than urban women. In addition, domestic violence programs serving rural communities offer fewer services for a greater geographic area than urban programs [85].
| A) | Black women | ||
| B) | Multiracial non-Hispanic women | ||
| C) | American Indian/Alaska Native men | ||
| D) | All of the above |
In the United States, intimate partner violence disproportionately affects women of color [97]. Black and multiracial non-Hispanic women have significantly higher lifetime prevalence of rape, physical violence, or stalking by an intimate partner [98]. Black, American Indian or Alaska Native, and multiracial non-Hispanic men have a significantly higher lifetime prevalence of rape, physical violence, or stalking compared with White non-Hispanic men. These findings may be a reflection of the many stressors that racial and ethnic minority communities continue to experience. For example, a number of social determinants of mental and physical health, such as low income and limited access to education, community resources, and services, likely play important roles. These factors and medical mistrust, historical racism and trauma, perceived discrimination, and immigration status may affect help seeking and the assessment of victims [97,158]. Level of acculturation should also be taken into account. Some studies have found there is a relationship between acculturation and interpersonal intimate violence. It is possible that as racial and ethnic minority women are exposed to Western norms, they are less likely to adhere to traditional gender roles. As they challenge these cultural norms, they are at increased risk of abuse [159].
| A) | Paranoia | ||
| B) | Schizophrenia | ||
| C) | Low self-esteem | ||
| D) | Possessiveness and jealousy |
Other studies demonstrate that abusive mates are generally possessive and jealous. Another characteristic related to the abuser's dependency and jealousy is extreme suspiciousness. This characteristic may be so extreme as to border on paranoia [101]. Domestic violence victims frequently report that abusers are extremely controlling of the everyday activities of the family. This domination is generally all encompassing and often includes maintaining complete control of finances and activities of the victim (e.g., work, school, social interactions) [101].
In addition, abusers often suffer from low self-esteem and their sense of self and identity is directly connected to their partner [101]. Borderline personality disorder, characterized by impulsivity, fluctuation of emotions, and instability in sense of identity and interpersonal relationships, has been identified as a risk factor for perpetrating domestic violence [160].
| A) | feet. | ||
| B) | arms. | ||
| C) | fingers. | ||
| D) | abdomen. |
In a study with 170 nurses, 56% stated that they have almost never screened their patients for domestic violence [161]. Several barriers to screening for domestic violence have been noted, including a lack of knowledge and training, time constraints, lack of privacy for asking appropriate questions, disruption to normal routines, lack of organizational policies, lack of supervision, personal discomfort, and the sensitive nature of the subject [49,130,161]. Although awareness and assessment for IPV has increased among healthcare providers, many are still hesitant to inquire about abuse [107]. At a minimum, those exhibiting signs of domestic violence should be screened. Typical injury patterns include contusions or minor lacerations to the head, face, neck, breast, or abdomen and musculoskeletal injuries. These are often distinguishable from accidental injuries, which are more likely to involve the extremities of the body. Abuse victims are also more likely to have multiple injuries than accident victims. When this pattern of injuries is seen, particularly in combination with evidence of old injury, physical abuse should be suspected [100].
| A) | should disregard the disclosures of unreliable reporters. | ||
| B) | is focused on law enforcement and perpetrator identification. | ||
| C) | creates a space that is supportive, safe, and conducive to healing. | ||
| D) | should only be attempted in inpatient mental healthcare settings. |
A trauma-informed approach to screening and care of victims of violence creates a space that is supportive, safe, and conducive to healing. Trauma-informed care principles emphasize that trauma affects many dimensions of an individual's and their family's lives. Practitioners should be mindful that triggers in the environment can result in retraumatization, and their responses can also inadvertently retraumatize the victim [163]. Therefore, universal trauma-informed education focuses less on formalized screening tools and checklists and more on creating spaces in which traumatic experiences are freely discussed. The space should be safe and there should be no distractions so the practitioner can actively listen and engage with the victim [163]. In this approach, the practitioner conveys universal information about intimate partner violence, in some cases tailored to the specific setting or patient population [111]. These settings "facilitate disclosure for victims of IPV and meet disclosure with empathy, competence, and appropriate referrals" [111]. This approach can be used in any healthcare or human services setting.
| A) | the 24-hour hotline. | ||
| B) | law enforcement officials. | ||
| C) | your immediate supervisor. | ||
| D) | a national domestic violence registry. |
In addition to providing acute care and scheduling follow-up appointments, providers should connect victims of violence with available resources. After identifying victims and their abusers, healthcare professionals should immediately implement a plan of action that includes providing a referral to a local domestic violence shelter to assist the victim and the victim's family. The acute situation should be referred immediately to local law enforcement officials. Other resources in an acute situation include crisis hotlines and rape relief centers.
| A) | Encourage the victim to be aware of weapons in the residence. | ||
| B) | Ensure that older children are not aware of the details of the plan. | ||
| C) | Recommend that copies of important documents and necessary items be available. | ||
| D) | Keep a bag packed with necessities and stored in a safe place in the event leaving must be immediate. |
All practitioners who deal with domestic and/or sexual violence should periodically review safety planning with victims. Homicide is of high risk for victims; therefore, safety planning is crucial. When advocating a safety plan, it is important to:
Encourage the victim to be aware of weapons in the residence.
Have victims make a plan of what to do if violence escalates and where to go if leaving is an option.
If children are old enough, they should be instructed about the safety plan and assigned roles.
When possible, victims should save some money in a private bank account or hide money for escape. Victims should be informed that if the abuser finds out about a separate bank account, they could be in danger.
Encourage victims to keep a bag packed with necessities and stored in a safe place in the event leaving must be immediate.
Advise victims to work out a code word or signal with the children so they will know when to implement an escape plan.
Encourage victims to keep a list of important phone numbers in their packed bag. Memorizing important numbers provides more safety.
Recommend that copies of important documents and necessary items be available.
Victims should check security settings on devices and change passwords.
| A) | lasts about 12 months. | ||
| B) | does not require the abuser to be present. | ||
| C) | does not require that a court date be scheduled. | ||
| D) | is not an option for victims of domestic violence. |
Protective orders do not require the involvement of the police and involve actions intended to protect the victim, including ensuring continuation of health insurance and removal of firearms [171]. In an analysis of 607 protective orders issued in Arizona, the most frequent request was that the petitioner's home be protected [171]. Victims can file for a temporary or permanent protective order. A temporary protective order does not require the abuser to be present. These orders last about 30 days or until a court date is scheduled. A permanent protective order requires both the victim and abuser to be present in court. Permanent protective orders last for about 12 months [121].