Family and domestic violence (including child abuse, intimate partner abuse, and elder abuse) is a common problem in the United States and Florida. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence.
Unfortunately, each form of family violence begets interrelated forms of violence, and the "cycle of abuse" is often continued from exposed children into their adult relationships, and finally to the care of the elderly.
Domestic and family violence include a range of abuse including economic, physical, sexual, emotional, and psychological toward children, adults, and elders.
Intimate partner violence includes stalking, sexual and physical violence, and psychological aggression by a current or former partner. In the United States, as many as one in four women and one in nine men are victims of domestic violence. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity.
The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The numbers of individuals affected is expected to rise over the next 20 years with the increase in the elderly population.
Domestic and family violence is difficult to identify, and many cases go unreported to health professionals or legal authorities. Due to the prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and physicians will at some point evaluate and possibly treat a victim or perpetrator of domestic or family violence.
Questions Health Professionals Need to Consider
What are the risk factors, signs, and symptoms of domestic or family violence?
What are the characteristics that define domestic or family violence?
What information is available to help health professionals assist the needs of victims of domestic or family violence?
What are the ethical and legal reporting requirements?
Healthcare Professional Recognition, Evaluation, and Referral
Healthcare professionals should be able to identify domestic and family violence victims and potential abusers.
Healthcare professionals should be able to assess all patients for abuse and offer counseling, education, and referral.
Domestic and family violence victims may suffer emotional, physical, and psychological abuse and need empathy and understanding.
Health professionals must be able to identify the signs and symptoms of a mental and physical disease, illness, and injury related to domestic violence and family violence and provide initial counseling of victims.
Injuries often require immediate evaluation and treatment after an assault; as a result, health providers are often the first to evaluate and identify domestic and family violence victims.
All healthcare professionals need to be aware of the presence of potential abuse victims in their clinical setting.
When healthcare professionals identify domestic or family violence, they should have a plan that includes providing community resource information related to shelter, counseling, advocacy groups, child protection, and legal aid.
Family and domestic violence are abusive behaviors in which one individual gains power over another individual.
Intimate partner violence typically includes sexual or physical violence, psychological aggression, and stalking. This may include former or current intimate partners.
Child abuse involves the emotional, sexual, physical, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm.
Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an elder.
Center for Disease Control and Prevention
Domestic violence, spousal abuse, battering, and intimate partner violence are terms used to describe the victimization of an individual with whom the abuser has an intimate or romantic relationship. The Centers for Disease Control and Prevention defines domestic as "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner."
Domestic and family violence has no boundaries. It occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referral.
Department of Children and Families
Domestic violence is defined by the Florida Department of Children and Families as "a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and control. It may include physical abuse, sexual abuse, emotional abuse, and economic abuse. It may also include threats, isolation, pet abuse, using children, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner."
Domestic violence under Florida law is defined as "any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another family or household member." Family members must "reside in the same single dwelling unit, with the exception of persons who have a child in common."
Violence Abuse Types
Violent abuse takes many forms, including stalking, economic abuse, emotional or psychological abuse, sexual abuse, neglect, Munchausen by Proxy, and physical abuse. Domestic and family violence occurs in all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or geographic limitation. It may occur in individuals with different sexual orientations.
Stalking is defined as repeated, unwanted attention that causes fear or concern for safety. This includes unwanted letters, emails, texts, or phone calls; watching, following, or spying; showing up repeatedly in the same place as the victim; damaging the victim’s property; making threats of harm.
Financial abuse occurs when an individual is forced to become dependent through improper use of money by a person in a trusting relationship. The abuser may also forbid employment or education to gain additional financial control. Examples include coercion to surrender, forgery, theft of possessions, and improper use of guardianship or power of attorney.
Emotional or Psychological Abuse
Emotional or psychologic domestic violence includes verbal and non-verbal communication which inflicts emotional or mental harm. Emotional or psychologic violence may be subtle, but it is often very harmful to the victim, resulting in depression and suicide.
Emotional or physical abuse may involve convincing the victim that the violence is their fault, that there is no way out of their situation, and that the victim is worthless and needs the abuser to exist. Many abusers will isolate their victims from friends, family, school, and work.
Child Relationship Control: Deliberately damaging relationship with a child
Coercive: Limiting resource access, possessiveness, and constant monitoring
Exploitation: Use of consequence to control choices, for example, “If you call the protective service, I could go to jail, and you will have no financial support.”
Expressive: Name-calling, degradation, and threats
Gaslighting: Presenting false information making the victim doubt his or her memory and perception; making victims question their sanity
Reproductive Control: Refusing birth control or forced pregnancy terminations
Threats: Use of gestures, words, or weapons that future harm may occur
Sexual violence is using physical coercion to force participation in unwanted sex acts. Perpetrators often incapacitate victims with alcohol or drugs. Some victims may be nursing home patients with mental disabilities or dementia.
Forced anal, oral, or vaginal penetration of a victim
Forced penetration of someone else
Sexual coercion involving intimidation to pressure consent
Unwanted exposure to pornography, harassment, sexual violence, filming, taking, or disseminating sexual photograph or video
Unwanted sexual contact
Neglect occurs when the well-being of a child or elder is ignored by an individual who is responsible for that well-being. Neglect is defined as a failure to provide for a dependent’s emotional, physical, or social needs. These include hygiene, nutrition, clothing, shelter, and access to health care. Abandonment is also a form of neglect.
Munchausen by Proxy
Munchausen syndrome by proxy is a factitious disorder where an individual fabricates or exaggerates mental or physical health problems in the person for whom he or she cares. The primary motive is to gain attention or sympathy. Unlike Munchausen syndrome, the deception involves not themselves, but someone under the person's care.
The use of physical power which results in injury, disability, or death are forms of physical violence. Other forms of physical violence include coercion, administering drugs or alcohol without permission, and denying medical care.
The Cycle of Abuse and Violence
Usually, abuse begins with verbal threats that escalate to physical violence. Violent events are often unpredictable, and the triggers are unclear to the victims. The victims live in constant fear of the next violent attack. Violence and abuse are perpetrated in an endless cycle involving three phases: tension-building, explosive, and honeymoon.
In the tension-building phase, the abuser becomes more judgmental, temperamental, and upset; the victim may feel she is "walking on eggshells." Eventually, the tension builds to the point that the abuser explodes.
During this phase the victim may try to calm, stay away, or reason with the abuser; often to no avail. The abuser is often moody, unpredictable, screams, threatens, and intimidates. They may use children as tools to intimidate the victim and family. They often engage in alcohol and illicit drug use.
The explosive phase involves the victim attempting to protect themselves and the family, possibly by contacting authorities. This phase may result in injuries to the victim.
The abuser may start with breaking items that progress to striking, choking, and rape. The victim may be imprisoned. Emotional, verbal, physical, financial, and sexual abuse is common.
During the honeymoon phase, the victim may set up counseling, seek medical attention, and agree to stop legal proceedings. They may hold the mistaken belief and hope that the situation will not happen again. Unfortunately, this is rarely the case.
The abuser may apologize, agree to counseling, beg forgiveness, and give presents. They may declare love for the victim and family, and promise to "never do it again."
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