What would you do if you suspected your friend, neighbor, or colleague were being abused by a spouse or partner? For many of us, it seems easier to turn away and ignore the signs. But today, greater public awareness of domestic abuse brings increased responsibility. If we see the signs, we can’t just turn a blind eye. This is especially true for healthcare providers. We may encounter domestic abuse victims in the course of routine care or when caring for a physical or psychological condition caused by such abuse. Because of our frequent contact with potential abuse victims and the nature of our relationship with them, we’re in a unique position to screen for abuse and intervene appropriately. We also play a legal role: Police and prosecutors may rely on our assessment and documentation of abuse-related injuries, and in some states we’re required by law to report suspected cases of domestic abuse. Despite our frequent contact with victims, too few of us have the training or education to recognize signs and symptoms of abuse and intervene effectively. Many of us feel uncomfortable even broaching the topic of abuse with patients.
Old problem, new term
Following the lead of the Centers for Disease Control and Prevention (CDC), many experts have replaced the term domestic abuse with intimate partner violence (IPV). The CDC defines IPV as physical, sexual, or psychological harm caused by a current or former spouse or partner. It can vary in frequency and severity from a single slap to chronic, severe battering. IPV occurs in all ethnic and cultural groups, at all socioeconomic and educational levels, in both heterosexual and same-sex couples. One study shows the incidence is decreasing among heterosexual couples; another suggests it’s rising dramatically among homosexual, bisexual, and transgender couples. Abused women have been the subject of much research, but few studies have focused on abused men. When assessing an adult male for possible abuse, don’t judge by appearance. A man who seems passive or effeminate isn’t necessarily the victim; nor is a man with exaggerated masculine characteristics necessarily the abuser. This article will increase your awareness and understanding of IPV. Throughout, I’ve used gender-neutral language to reflect the reality that IPV victims and their abusers can be of either sex.
Seeing the big picture
Statistics shed light on the scope of the problem. The CDC estimates that nearly 5.3 million IPV incidents occur each year among U.S. women ages 18 and older, and 3.2 million incidents occur among men. In the United States:
- IPV accounts for 22% of violent crimes against women and 3% of violent crimes against men.
- Approximately 1.5 million women and 835,000 men are raped or physically assaulted every year by an intimate partner, resulting in almost 2 million injuries and 1,300 deaths.
- From 1976 to 2002, about 11% of homicide victims were killed by an intimate partner.
Types of abuse
IPV can be physical; emotional, psychological, or verbal; sexual; or financial.
Physical abuse is the use of physical force that causes injury or the risk of injury. Ranging from physical restraint to murder, it may take the form of hitting, kicking, punching, slapping, strangling, shaking, confining, burning, freezing, pushing, tripping, scratching, cutting, burning, biting, pinching, or throwing things—as well as assault with a weapon. Hiding medications and hindering a person from taking medications also are considered types of physical abuse. (See Health consequences of intimate partner violence by clicking the PDF icon above)
Emotional, psychological, and verbal abuse
Emotional, psychological, and verbal abuse commonly accompany physical abuse—and in some ways can be even more damaging. Such abuse may involve:
- mocking or criticism of the partner’s physical appearance or racial or cultural background
- threats to harm or kill the partner, destroy the partner’s property, or ruin the partner’s reputation (as by exposing the partner’s HIV-positive status or sexual orientation or identity, or by spreading lies about the partner)
- use of threatening nonverbal behavior, such as menacing movements, gestures, or facial expressions. (See Other types of emotional any psychological abuse by clicking the PDF icon above.)
Sexual abuse can be physical, psychological, or both. The abuser may:
- coerce the partner through force or threats of force to engage in sex against his or her will (with the abuser, another person, or an animal)
- make demeaning and degrading sexual comments about the partner
- examine or smell the partner’s body in an attempt to find out if the victim has had sex with another person.
In financial abuse, the abuser limits the partner’s access to money as a way of exerting control. For instance, the victim may be required to do all the work while the abuser keeps the earnings. Or the abuser may forbid the victim from working yet require him or her to handle all financial concerns; if money problems arise, the abuser accuses the victim of misappropriating funds. The abuser may hide money and be secretive about financial matters. To prevent the victim from leaving the relationship, the abuser might create debt for both, making it difficult for the victim to get credit or loans and thus to leave the abuser.
Many female IPV victims were raised with rigid traditional views regarding male and female roles; some have a history of exposure to violence. Other common traits include dependency, passivity, submissiveness, and low self-esteem.
As children, most abusers were abused themselves or witnessed the abuse of a loved one. That they go on to abuse others shows how difficult it is to stop the cycle of violence. Common characteristics of abusers include personality disorders, substance abuse, aggressive behavior, low self-esteem, difficulty expressing oneself, excessive jealousy, and belief in rigid sex role stereotypes. Many abusers are extremely seductive, possessive, and manipulative. Some seem childlike in their need for nurturing; others display inappropriate anger and resentment toward the partner. Abusers can come from any socioeconomic level, but the incidence is higher among people who are unemployed or have low-prestige jobs. Some abusers share their stories to gain sympathy. They may play up their insecurities and tell you they feel powerless. You might feel sorry for an abuser who says, “I didn’t mean to do it. I told myself to stop, but I just snapped.” However, getting people to fall for their stories is exactly what many abusers want. Some abusers turn the tables on the victim by showing bite marks or scratch marks. They may deny or minimize the problem, blame it on the victim, or claim the abuse was a one-time event or that they only occasionally get angry. But IPV isn’t an isolated event—a single slap or exchange of hurtful words. It’s a learned behavior. More than likely, the abuser has a pattern, a plan, and the intent to manipulate and coerce to gain control over the partner.
Slipping into the violence cycle
According to the cycle of violence model, defined by Lenore Walker in her 1979 book The Battered Woman, most abusive relationships have a distinct pattern and go through several phases.
- Phase 1. Tension builds. Violence is minimal but verbal, emotional, and psychological abuse occur. Victims might believe they can control the situation through their own actions.
- Phase 2. Physical abuse begins. The victim feels powerless and may deny the extent of injury. Many victims don’t seek much-needed medical treatment, or the abuser may prevent the victim from seeking it.
- Phase 3. Sometimes dubbed “the honeymoon,” this phase is marked by tranquility. The abuser may apologize profusely and promise never to lose control again. The victim wants to believe the violence has ended. Unfortunately, this is seldom true; usually, the abuse simply takes on a new disguise and the cycle repeats.
Assessing patients for abuse
Few victims come right out and ask for help. Shame and fear of reprisal stop many from reporting their plight to anyone. To identify IPV victims and mitigate the effects of abuse, healthcare providers first need to explore their own attitudes, beliefs, and feelings toward IPV, because these could affect the care we provide—perhaps even to the point where we overlook a potential problem despite warning signs. Be open and honest with yourself as you evaluate your prejudices, cultural upbringing, and perhaps even your own experience with abuse. When screening for abuse, provide a safe, quiet, private setting with only yourself and the patient present. Never assume an adult who accompanies an injured patient is not an abuser. In many cases, the suspected abuser comes to the hospital or clinic with the victim, stands nearby, answers questions for the victim, and tries to assist by taking care of the victim’s belongings. Whenever possible, find a way to dismiss this person from the screening and examination. Once you’re alone with the patient, let the patient speak at his or her own pace. To encourage the patient to go on, show support by stating, “You’re not alone” and “I believe what you’re saying.” If the patient is hearing impaired or doesn’t speak a language you’re fluent in, use your facility’s translation program. Don’t ask anyone accompanying the patient to translate; the patient may be too intimidated or ashamed to speak freely to this person.
Too often, healthcare providers fail to recognize IPV victims because physical signs and symptoms are subtle or absent. But appropriate screening can make victim recognition easier. Be sure to follow your facility’s policy on screening. (For reliable, validated assessment tools, visit www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm.) The American College of Obstetrics and Gynecology recommends the following screening questions:
- Has your partner or anyone close to you threatened or physically hurt you?
- During the past year, have you been kicked, punched, slapped, or otherwise hurt?
- Has your partner or anyone else forced you to have sex or participate in sexual activities that made you feel uncomfortable?
Although screening is similar whether the patient is heterosexual, homosexual, bisexual, or transgendered, you should tailor your assessment (as well as intervention, planning, and follow-up) to the individual.
When to suspect abuse
The following behaviors and injury patterns should raise your suspicion that the patient may be an IPV victim:
- The patient hesitates when explaining how an injury occurred, avoids eye contact, appears depressed and passive, and cries easily.
- The patient’s explanation for the injury doesn’t match the injury mechanism or characteristics.
- You detect signs of old injuries (especially to the knees), which could signify previous violence.
- The patient complains of a stiff neck or sore shoulders—possible symptoms of forceful or violent shaking.
- You detect marks on the neck, which may reflect a strangulation attempt.
- The patient has vaginal or anal tears or a fracture of the jaw, arm, pelvis, rib, collarbone, or leg.
- You find injuries in different healing stages, defensive injuries (those to the back of the arm incurred when fending off an attack), bite marks, and bruises or welts in the shape of a belt buckle.
Vague complaints (such as GI problems, chest or back pain, fatigue, and insomnia) may reflect more subtle types of abuse. If a wide array of tests yields no explanation for the patient’s complaints, this may represent a silent cry for help.
Four key questions
If you suspect your patient has been abused, ask the four “W” questions:
- What happened?
- Who did this?
- Where did this happen?
- When did this happen?
Document the patient’s responses in his or her exact words, using quotation marks. Include objective findings, such as patient grooming, posture, and mannerisms.
Caring for IPV victims can be challenging, but tools are available. (See ABCDEs of caring by clicking the PDF icon above.) Encourage a patient who reports or admits to being an IPV victim to talk and express feelings about the abuse. Show concern and compassion, and ask if the patient is all right. To promote candid responses, stay calm and nonjudgmental. Provide reassurance that the patient isn’t alone. Emphasize that no one has to live with violence and that help is available. If the patient gives consent, take several photos of the patient’s injuries before treatment begins (See Collecting photographic evidence by clicking the PDF icon above.) Next, identify the patient’s options through problem solving. Ask what the patient would like to do about the abuse. Discuss the possibility of staying with a friend or family member. As needed, provide information about local abuse shelters and direct the patient to counseling resources, social services, the police, and appropriate culture-specific community support groups.
Devising a safety plan
IPV victims who choose to stay with their abusers need to have a safety plan to use in case the partner becomes violent again. Offer the following guidelines:
- During an altercation, stay away from the bathroom, kitchen, or any place where weapons are likely to be present.
- Practice how to get out of your home safely.
- Pack a bag with necessities and important documents and keep it somewhere safe, such as at a friend’s house. (See What to take when leaving an abusive partner by clicking the PDf icon above.)
- Devise a code word to use if you want a neighbor, friend, or family member to call the police.
Documentation and reporting
In your documentation, describe all the patient’s injuries and use a body map to show their locations. Be sure to include all fractures, scrapes, bruises, and complaints of pain. IPV victimization reporting is mandatory in California, Colorado, and Kentucky. However, many more states have specific guidelines for reporting violent injuries inflicted by fire, firearms, and sharp objects as well as injuries likely to cause death. Familiarize yourself with state laws regarding documentation and mandatory reporting. If your state requires you to report IPV, inform the patient of any limitations on confidentiality beforehand. All health systems and healthcare providers should establish policies that ensure patients’ medical records are kept as confidential as possible. For state reporting regulations, forensic evidence collection procedures, and confidentiality guidelines, see http://www.endabusewi.org/, Appendices J, K, and L. Or call a local shelter or the district attorney’s office.
Documentation pitfalls to avoid
In cases of suspected IPV, your documentation could help or hinder legal actions against the abuser and could expose you and your employer to legal liability. Here are some examples:
- Never document that a patient has been “choked.” Legally, choking refers to presence of a foreign object caught in the trachea or esophagus. If you write that you believe the patient was choked by an intimate partner, authorities might decide not to charge the abuser or might drop any charges already lodged. Instead, document that the patient was “strangled,” which means someone put his or her hands around the patient’s throat and squeezed.
- Be sure to document all interventions. Otherwise, you and your employer could be held liable if the patient comes to harm after leaving the facility.
Immediate needs of an IPV victim may include a follow-up appointment with the primary healthcare provider, housing in an abuse shelter, counseling, legal and financial assistance, job training, and help from a support system. Express your concern for the patient’s health and safety, and provide information about available social services and the role of the domestic abuse advocate in your facility or community. Tell the victim how to get in touch with the police, if desired.
What if the patient denies abuse or declines help?
If you strongly suspect abuse even though the patient denies it, record your suspicion and tell the patient that resources are available if he or she chooses to use them at a later time. If the victim admits abuse but declines help and decides to go back to the abusive relationship, assess the risk for continued abuse, identify available options, and develop a safety plan, as discussed earlier. Make sure the patient knows what to do to survive. If your facility has a preprinted card with emergency contact numbers for IPV victims, provide it. If not, write down these numbers on a small piece of paper that can be hidden easily and give it to the patient. Be sure to document these interventions. Remember—even if you believe the violence won’t end, it’s not your role to rescue a victim who doesn’t want to be rescued or to encourage the victim to leave the abuser. Trust that the victim knows the situation best and will leave when the time is right. Some victims decide to stay for cultural, financial, or religious reasons; fear of losing their children; or lack of confidence and support from family and friends. Don’t urge a victim to leave the abuser before he or she is ready, because leaving an abusive relationship is the most dangerous time.
Saving current and future IPV victims
IPV affects the health and well-being not just of individual victims but of future generations, too. Studies show that children from families touched by IPV have an increased incidence of physical symptoms, aggressive behavior, school dysfunction, and learning disabilities. Many grow up to become abusers. Infants of pregnant women who experience IPV are at higher risk for prematurity, low birth weight, and neonatal death. Become a frontline soldier in the battle against IPV. Learn as much as possible about IPV and implement abuse screening for all patients. Despite the time constraints of today’s healthcare environment, take the time to ask the patient, “Are you really OK?” I hope that after reading this article, you’ll take the few extra minutes needed to assess your patients for IPV.
Family Violence Prevention Fund. National consensus guidelines on identifying and responding to domestic violence victimization in healthcare settings. Available at: http://www.endabusewi.org/. Accessed April 25, 2007.
Klaus P. Crime and the nation’s households, 2002. Bureau of Justice Statistics, Bulletin. Available at: http://www.ojp.usdoj.gov/bjs/pub/pdf/cnh02.pdf. Accessed April 25, 2007.
Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World report on violence and health. Geneva, Switzerland: World Health Organization; 2002.
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Thompson M, Basile K, Hertz M, Sitterle D. Measuring intimate partner violence victimization and perpetration: a compendium of assessment tools. Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2006. Available at: www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm. Accessed April 25, 2007.
For a complete list of selected references, visit www.AmericanNurseToday.com.
Melissa Renee Schwartz, MSN, BSN, RNC, is a Clinical Instructor at East Carolina University School of Nursing in Greenville, N.C. The author does not have any financial arrangements or affiliations with any corporations offering financial support or educational grants for continuing nursing education activities.