Domestic Violence

What is Domestic Violence?

Family and domestic violence is a widespread issue in the United States, affecting an estimated 10 million people each year. This includes child abuse, abuse of intimate partners, and elder abuse. It’s a major public health problem that healthcare professionals regularly encounter. Sadly, different forms of such violence are often interrelated, creating a “cycle of abuse” that can carry on from childhood into adult relationships and into the care of the elderly.

This type of violence includes many different forms of abuse such as economic, physical, sexual, emotional, and psychological abuse, impacting children, adults, and elders. Intimate partner violence might involve stalking, sexual and physical violence, or psychological aggression by a current or former partner. In the U.S., up to one in four women and one in nine men are victims of such abuse, however, it’s believed these crimes often go unreported.

The impacts of family and domestic violence are widespread, affecting not just the victims, but also their families, co-workers, and communities. It harms psychological and physical health, reduces quality of life, and lowers productivity. It’s estimated that the national economic cost of this violence exceeds 12 billion dollars each year. Furthermore, the number of people affected by this issue is expected to rise over the next 20 years, particularly in the elderly population.

Regrettably, this kind of violence can be hard to detect, and many cases are not reported to healthcare professionals or legal authorities. Nonetheless, given its prevalence, it’s likely that all healthcare professionals – including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and doctors – will encounter victims or perpetrators of family or domestic violence in their careers.

Family and domestic violence involve abusive behaviors where one person seeks to control another. Intimate partner violence might include sexual or physical violence, psychological aggression, and stalking, involving either current or former partners. Child abuse refers to emotional, sexual, physical, or neglectful acts by a parent, guardian, or caregiver toward a child under 18 that causes potential harm, direct harm, or a threat of harm. And elder abuse is an intentional or negligent act by a caregiver that poses a risk or directly causes harm to an older person.

The Center for Disease Control and Prevention (CDC) defines domestic violence as physical or sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former partner. It’s essential to understand that this form of violence can happen in intimate relationships regardless of culture, race, religion, or socioeconomic status, and it’s a prevalent issue in our society. Healthcare professionals must be able to recognize these situations and provide the necessary help.

The types of violence vary greatly, including stalking, economic, emotional/psychological, sexual, neglectful, and physical abuse, even extending to rare cases of Munchausen by proxy. This violence knows no bounds; it happens across all races, ages, and sexes, in any cultural, socioeconomic, educational, religious, or geographical context, and amongst individuals of all sexual orientations.

What Causes Domestic Violence?

Abusers often feel the need to control others due to a range of personal issues. These may include problems with managing anger, feelings of jealousy or low self-esteem, and feelings of inadequacy. Some may feel culturally entitled to control their partners, while others may have personality or psychological disorders. Learned behavior, such as observing domestic violence while growing up, can also drive the abuse. Lastly, abusers may be inclined towards violence when under the influence of alcohol or drugs, as their ability to control violent impulses may decrease.

Various factors can make individuals more likely to become victims or perpetrators of domestic and family violence. These factors can be personal, linked to relationships, connected to community situations or societal issues. For example, a person with lower education levels is more likely to be involved in domestic violence. Adults who were abused as children often continue the cycle of violence in their own relationships. Similarly, those with a history of drug and alcohol abuse are more likely to participate in domestic violence.

Children who witness or experience domestic violence may grow to believe that violence is a normal way to solve conflicts. Boys who grow up without learning to respect women equally can become abusive towards women in adulthood. Girls who grow up witnessing domestic violence are more likely to become victims of abuse in their own relationships. However, it’s important to note that domestic violence is not restricted to any specific gender – both men and women can be victims or perpetrators.

The abusive behavior often involves emotional, physical, or sexual abuse. This stems from a combination of personal and situational factors. For example, an individual might learn violent behavior from their family, community, or cultural practices if they grow up seeing or experiencing violence.

Risk Factors and Frequency for Domestic Violence

Domestic violence is a serious public health issue. It affects around one in three women and one in ten men aged 18 and above. Every year, over 1500 deaths in the U.S are related to domestic violence.

Victims often suffer severe injuries that require hospital or clinical care, which involve significant costs. It is estimated that acute domestic violence-related medical and mental health care services cost over $8 billion annually. If a victim suffers a long-term condition due to the violence, the cost becomes considerably higher.

Domestic violence is often linked to financial difficulties and job loss. Calls to the National Domestic Violence Hotline tend to increase during an economic downturn. However, the rate of nonfatal domestic violence cases is decreasing, likely due to factors such as a decline in marriage rates, improved female economic status, better access to domestic violence shelters, and an aging population.

Many victims and perpetrators do not seek help.
Healthcare professionals, especially nurses, often have the first chance to identify domestic violence.
Domestic violence can affect anyone: women, men, parents, and children.
Half of the women seen in emergency departments have experienced abuse, and 40% of domestic violence fatalities sought help within the two years leading up to their death.
Only one third of domestic violence victims identified by police are identified in the emergency department.
Healthcare professionals who work in acute care should be vigilant for signs of domestic violence, as the abuser might pose as a supportive family member.

Child abuse is linked to factors such as age, family income, and ethnicity. Gender is a risk factor only for sexual abuse. Every year, over 3 million referrals are made to child protection authorities, yet only about 10% of them come from medical personnel. There are approximately two child abuse-related deaths per 100,000 children each year, with slightly over half of the perpetrators being women.

According to the CDC, one in four women and one in seven men will experience physical violence from their intimate partner at some point in their lives.
About one in three women and nearly one in six men experience sexual violence at some point.
One in six women and one in nineteen men have been stalked, typically by someone they know.
Every year, at least five million acts of domestic violence affect women over 18, and over three million impact men.
In some cases, domestic violence escalates to serious or even fatal injuries.

While it’s hard to get exact numbers on elderly abuse due to underreporting and the difficulty of collecting data, it is believed to occur in 3% to 10% of the elderly population. Underreporting is often due to fear, guilt, lack of knowledge, or shame felt by the victims and clinicians’ challenges in identifying and reporting cases.

Signs and Symptoms of Domestic Violence

It’s important for a medical exam and patient history to be tailored to the individual’s age. Understanding the common signs of abuse in various age groups or scenarios is crucial to identify potential victims and offer the necessary help and support.

Child Abuse

For young children, abuse often shows up as unexplained fractures, bruises, and internal bleeding. In pre-walking children, any injury is a potential red flag. Injuries to the ears, neck or torso need to be explained by caregivers or thoroughly investigated. Abused children may lack personal care and nutrition, display aggressive or shy behaviors, struggle with communication, or become disruptive or hyperactive. Their school attendance is often inconsistent.

Intimate Partner Abuse

Intimate partner abuse affects both sexes, although women are more frequently victims. Common injuries include those to the head, neck, and face. Injuries may be hidden under clothing, such as wounds to the body, breasts, genitals, rectum, and buttocks. If the explained cause of injury doesn’t match the actual injury, it’s a cause for concern. Symptoms of psychological distress like anxiety, depression, or fatigue are common, as well as complaints of physical symptoms like headaches, chest pain, or chronic pain.

Intimate Partner Abuse: Pregnancy and Female

Abuse can result in up to 10% of hospital admissions during pregnancy. Various signs may help medical professionals identify abuse victims. If there are suspected signs or symptoms, it’s important to examine the patient privately while explaining the importance of confidentiality. The provider should ask compassionate questions and patiently listen to the responses.

Intimate Partner Abuse: Same-Sex

Abuse in same-sex relationships is more widespread than you may think. It affects women more than men, with 40% of lesbian women experiencing domestic violence. Abusers may also threaten to reveal their partner’s sexual orientation as a control method. It’s important for professionals to understand there are fewer resources for these victims and they may share friends or support groups with their abusers.

Intimate Partner Abuse: Men

Men can also be victims of domestic violence, making up approximately 15% of all cases. They are less likely to seek medical care, potentially underreporting the prevalence of abuse. There may be a history of childhood abuse among male victims.

Elderly Abuse

Elders, too, can be abuse victims. It’s important for health professionals to ask about potential abuse, even if signs are not directly perceptible.

Dementia
Mental health issues, drug or alcohol abuse in the abuser
Living with the abuser
Social isolation

Testing for Domestic Violence

Identifying injuries related to domestic abuse can be a difficult task. The most pressing injuries, those that pose a threat to life or limb, are always first treated and examined. After the immediate danger has been handled, the healthcare providers might want additional testing, which could include laboratory tests, x-rays, CT scans, or MRI scans. Remember, the main priority should be addressing the reason the victim ended up in the emergency room.

Every medical examination starts with a history and physical assessment. All women should be checked for signs of domestic abuse, and if they show positive signs, even without any physical symptoms, they should be referred accordingly. Every medical facility should have well-defined plans and procedures designed to screen, assess, and refer patients who may be victims of intimate partner or domestic violence. These plans should include how to refer a patient, how to document the abuse, and how to follow-up. Medical professionals need to be aware of the hurdles involved in screening for domestic abuse, such as the lack of time, the delicate nature of the subject, proper training, and ensuring a private environment to discuss the issues. Despite increased awareness about abuse both in public and professional realms, many patients and healthcare providers are still reluctant to talk about it.

Patients displaying signs and symptoms of domestic violence should be properly evaluated. The blatant signs are physical, like bruises, bites, cuts, broken bones, gunshot or knife wounds, burns, and concussions. Some common patterns of injuries seen in domestic violence include bruises on the head, face, neck, chest, abdomen, and skeletal injuries. In contrast, accidental injuries usually affect the body’s extremities. Victims often have multiple injuries at different healing stages, ranging from acute to chronic. They might also display mental health issues like anxiety and depression. Somatic symptoms such as fatigue, backache, stomachache, headaches, restlessness, decreased appetite, and insomnia might also be present. In addition, women victim to domestic abuse have a higher chance of suffering asthma, irritable bowel syndrome, and diabetes.

A thorough assessment of the victims should ideally occur once they’ve revealed the abuse, provided they are stable and not in severe pain. The first and foremost priority should always be their safety. Standard, prepared questions can help put the patients at ease during the examination. If there is immediate danger, they should be referred to advocate support, a victim hotline, legal authorities, or a shelter.

If there is no immediate danger, the assessment should investigate both the mental and physical health of the victim and establish a history of current or past abuse. These answers help determine the next best steps or interventions. During the initial assessment, the healthcare provider must be careful to respect the patient’s cultural beliefs. Combining a cultural sensitivity assessment with a history of domestic violence might allow for more effective treatment.

Even when given the option, not all patients that have suffered domestic violence may want a referral. Many victims are often fearful for their lives and financial security. Hence, they may be weighing the costs of leaving their abuser, including losing financial support and potentially having to care for children on their own. Healthcare providers must reassure the patient that the decision is entirely their own and that they will provide help, regardless of their choice. The goal is to make resources accessible, enhance support, and ensure safety. If the patient decides to leave their current situation, they should be given information to local domestic violence shelters for assistance. If their life or limb is at risk, or if there is evidence of any injury, they should be referred to local law enforcement officials. Commonly, counselors who specialize in the care of abused partners and children can include psychiatrists, social workers, and psychologists.

When assessing children for signs of abuse, a close history and careful physical exam are necessary. If head trauma is suspected, it might be appropriate to consult an ophthalmology specialist. Laboratory testing can be crucial for forensic examination and criminal prosecution, as sometimes certain diseases can mimic child abuse symptoms. As such, these diseases must be ruled out first.

Similarly, for elderly patients and their intimate partners, the examination should include checks for signs of dehydration, infection, improper medication administration, electrolyte abnormalities, substance abuse, and malnutrition. When needed, X-rays or CT scans can locate fractures or internal bleeding, respectively. If sexual assault is suspected, a pelvic examination should be conducted to collect evidence.

Documentation of any case of domestic or family violence is critical, especially when it results in legal action against the abuser. The best option is to have a team specializing in domestic violence to assist with evidence collection. Any evidence collected, such as tissue, blood, urine, saliva, and vaginal or rectal samples or even clothing stained with blood, saliva, semen, or vomit, should be handled and stored carefully as per the law enforcement guidelines.

Treatment Options for Domestic Violence

When a person visits the emergency room or doctor’s office, their immediate medical concerns are dealt with first. However, once the patient is stable, healthcare professionals might notice signs of domestic violence. Keeping the patient safe is of utmost importance. They will diagnose any physical injuries and treat acute conditions.

Identifying possible sources of domestic violence and establishing it as a diagnosis is crucial. The healthcare team will ensure the patient understands that they are not to blame for the situation. The patient’s emotional state will also be evaluated and addressed accordingly.

The team will document medical findings, potential risks to the patient, and any interventions made. They’ll also discuss the possibility of escalating violence with the patient and decide if legal action is necessary. The healthcare providers will assist the patient in making a follow-up plan and offer them options for shelter, legal help, and counseling.

The patient’s medical record is a vital piece of evidence that can be used in legal proceedings against the abuser. Medical professionals should document all evaluations, treatments, and referrals thoroughly. They should jot down the patient’s account of the abusive event, their behavior, and any health problems related to the abuse. Information about the alleged abuser, any physical injuries, and relevant photographs should also be included in the record.

In cases of sexual assault, healthcare professionals must follow specific protocols for physical examination and evidence collection.

If a patient opts not to go to a shelter, they should be provided with contact information for domestic violence hotlines and support services. They should be given necessary instructions discreetly, as written materials could pose a threat if found by the perpetrator upon the patient’s return home.

The healthcare team should encourage the patient to follow up with their primary care provider or another appropriate resource. They should also advise the patient on developing a safety plan.

It’s worth noting that many victims of domestic violence never contact the police, and some of them end up in hospitals before a sad turn of events. Healthcare professionals play a significant role in helping victims of domestic violence find the necessary help and support.

Different injuries in children need to be diagnosed differently. Here’s a guide on what doctors usually look for:

Head Injuries:

Accidental injuries
Rare blood vessel problems (Arteriovenous malformations)
Bacterial meningitis (a severe infection)
Trauma from birth
Blood clot in the brain (Cerebral sinovenous thrombosis)
Hemophilia (a blood clotting disorder)
Brain tumors

Bruises/Contusions:

Accidental bruises
Trauma from birth
Bleeding disorders
Marks from coining or cupping (alternative medicine practices)
Mongolian spots (blue or purple birthmarks)
Erythema multiforme (a skin reaction)
Hemangiomas (birthmarks from blood vessels)
Hemophilia

Burns:

Accidental burns
Atopic dermatitis (eczema)
Contact dermatitis (a skin reaction)
Impetigo (a bacterial skin infection)
Inflammatory skin conditions
Sunburns

Fractures:

Accidental
Trauma from birth
Congenital syphilis (a sexually transmitted infection)
Cancer
Brittle bone disease (Osteogenesis imperfecta)
Bone infection (Osteomyelitis)
Soft or brittle bones from Vitamin D deficiency (Rickets)
Scurvy (Vitamin C deficiency)
Type of fracture common in toddlers (Toddler’s fracture)

What to expect with Domestic Violence

Without the right social and mental health support, abuse can keep happening and get worse over time, making it hard for the people involved to recover. If left untreated, abuse in a household or family setting usually comes back and gets worse, both in how often it happens and how severe it is.

* More than 75% of people hurt by domestic violence continue to face abuse.

* Over half of women who have been beaten and made an attempt to take their own lives will try again; the second attempt often ends their lives.

In kids, the chance for negative outcomes is especially high, as abuse can have effects that last a lifetime. Besides dealing with physical injuries, the impact on mental health can be devastating. Research shows a strong link between sexual abuse in childhood and a higher risk of mental illnesses later in life. The cycle of violence could continue from childhood into adulthood in many cases.

Kids growing up in families where sexual abuse takes place may develop various issues like:

* Attention-Deficit/Hyperactivity Disorder (ADHD)
* Conduct disorder
* Depression
* Bipolar disorder
* Panic disorder
* Sleep disorders
* Attempts to take their own lives
* Post-Traumatic Stress Disorder (PTSD)

Health Impact

There are numerous known negative health effects of violence in family and domestic settings. Injuries like broken bones, brain injuries, and internal injuries can have long-term effects.

Patients may also develop various other health issues like:

* Asthma
* Difficulty sleeping
* Fibromyalgia (a condition that causes pain all over the body)
* Headaches
* High blood pressure
* Chronic pain
* Stomach disorders
* Gynecologic disorders
* Depression
* Panic attacks
* PTSD.

Frequently asked questions

Domestic violence refers to physical or sexual violence, stalking, and psychological aggression by a current or former partner. It can occur in intimate relationships regardless of culture, race, religion, or socioeconomic status. It encompasses various forms of abuse, such as economic, emotional, psychological, sexual, neglectful, and physical abuse.

Domestic violence affects around one in three women and one in ten men aged 18 and above.

Signs and symptoms of domestic violence can vary depending on the age group or scenario. Here are some signs and symptoms of domestic violence in different contexts: Child Abuse: - Unexplained fractures, bruises, and internal bleeding - Injuries to the ears, neck, or torso that need explanation - Lack of personal care and nutrition - Aggressive or shy behaviors - Communication struggles - Disruptive or hyperactive behavior - Inconsistent school attendance Intimate Partner Abuse: - Common injuries to the head, neck, and face - Hidden injuries under clothing, such as wounds to the body, breasts, genitals, rectum, and buttocks - Inconsistency between the explained cause of injury and the actual injury - Symptoms of psychological distress like anxiety, depression, or fatigue - Complaints of physical symptoms like headaches, chest pain, or chronic pain Intimate Partner Abuse: Pregnancy and Female: - Signs during pregnancy that may indicate abuse - Importance of examining the patient privately and ensuring confidentiality - Asking compassionate questions and actively listening to responses Intimate Partner Abuse: Same-Sex: - Higher prevalence of abuse among lesbian women - Threats to reveal partner's sexual orientation as a control method - Limited resources for victims in same-sex relationships - Potential overlap in friends or support groups with the abuser Intimate Partner Abuse: Men: - Men can also be victims, making up approximately 15% of all cases - Less likely to seek medical care, leading to potential underreporting - History of childhood abuse among male victims Elderly Abuse: - Signs may not be directly perceptible, so it's important to ask about potential abuse - Factors such as dementia, mental health issues, drug or alcohol abuse in the abuser, living with the abuser, and social isolation can contribute to elderly abuse.

Abusers often feel the need to control others due to a range of personal issues such as problems with managing anger, feelings of jealousy or low self-esteem, and feelings of inadequacy. Some may feel culturally entitled to control their partners, while others may have personality or psychological disorders. Learned behavior, such as observing domestic violence while growing up, can also drive the abuse. Additionally, abusers may be inclined towards violence when under the influence of alcohol or drugs.

The doctor needs to rule out the following conditions when diagnosing Domestic Violence: - Accidental injuries - Rare blood vessel problems (Arteriovenous malformations) - Bacterial meningitis (a severe infection) - Trauma from birth - Blood clot in the brain (Cerebral sinovenous thrombosis) - Hemophilia (a blood clotting disorder) - Brain tumors - Bleeding disorders - Marks from coining or cupping (alternative medicine practices) - Mongolian spots (blue or purple birthmarks) - Erythema multiforme (a skin reaction) - Hemangiomas (birthmarks from blood vessels) - Atopic dermatitis (eczema) - Contact dermatitis (a skin reaction) - Impetigo (a bacterial skin infection) - Inflammatory skin conditions - Sunburns - Congenital syphilis (a sexually transmitted infection) - Cancer - Brittle bone disease (Osteogenesis imperfecta) - Bone infection (Osteomyelitis) - Soft or brittle bones from Vitamin D deficiency (Rickets) - Scurvy (Vitamin C deficiency) - Type of fracture common in toddlers (Toddler’s fracture)

The types of tests that may be needed for domestic violence include: - Laboratory tests: These tests can help assess the overall health of the victim and rule out any underlying medical conditions. They may include blood tests, urine tests, and other diagnostic tests. - X-rays: X-rays can be used to detect fractures or other skeletal injuries that may be a result of domestic violence. - CT scans: CT scans can provide detailed images of the internal organs and structures, and they may be used to identify any internal injuries or bleeding. - MRI scans: MRI scans can provide more detailed images of soft tissues, such as the brain or spinal cord, and they may be used to evaluate any injuries or trauma to these areas. It's important to note that the specific tests ordered will depend on the individual patient's symptoms and presentation, and the healthcare provider will determine the most appropriate tests based on the situation.

When a person visits the emergency room or doctor's office, their immediate medical concerns are dealt with first. However, once the patient is stable, healthcare professionals might notice signs of domestic violence. Keeping the patient safe is of utmost importance. They will diagnose any physical injuries and treat acute conditions. Identifying possible sources of domestic violence and establishing it as a diagnosis is crucial. The healthcare team will ensure the patient understands that they are not to blame for the situation. The patient's emotional state will also be evaluated and addressed accordingly. The team will document medical findings, potential risks to the patient, and any interventions made. They'll also discuss the possibility of escalating violence with the patient and decide if legal action is necessary. The healthcare providers will assist the patient in making a follow-up plan and offer them options for shelter, legal help, and counseling. In cases of sexual assault, healthcare professionals must follow specific protocols for physical examination and evidence collection.

When treating domestic violence, there may be several side effects or considerations to keep in mind. These can include: - Emotional impact: Treating domestic violence can have emotional side effects on the patient, as they may be dealing with trauma, fear, and feelings of guilt or shame. Healthcare professionals should evaluate and address the patient's emotional state accordingly. - Legal considerations: In some cases, legal action may be necessary to protect the patient and hold the abuser accountable. Healthcare providers may need to discuss the possibility of escalating violence with the patient and decide if legal action is appropriate. - Documentation: The patient's medical record is a vital piece of evidence that can be used in legal proceedings. Healthcare professionals should thoroughly document all evaluations, treatments, referrals, and any relevant information about the abusive event, injuries, and the alleged abuser. - Safety planning: Healthcare professionals should assist the patient in making a follow-up plan and offer options for shelter, legal help, and counseling. They should also advise the patient on developing a safety plan to protect themselves from further harm. - Privacy and discretion: It is important to provide information and instructions discreetly, as written materials could pose a threat if found by the perpetrator. Healthcare professionals should ensure the patient's safety and privacy when providing contact information for domestic violence hotlines and support services. - Follow-up care: Encouraging the patient to follow up with their primary care provider or another appropriate resource is crucial. Healthcare professionals should provide ongoing support and guidance to help the patient access the necessary help and support.

Any healthcare professional, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and doctors, can provide assistance for domestic violence.

Abuse Domestic Violence Elder Abuse Injury Safety and Violence