DOMESTIC VIOLENCE HOMESTUDY - 2 HOURS |
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or fax to: (305) 651-1427 |
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III. HELPING AND REFERRING VICTIMS AND PERPETRATORS Since domestic violence occurs in approximately one out of three intimate relationships, both heterosexual and homosexual, chances are great that a healthcare provider will encounter both victims and perpetrators of domestic violence on a routine basis. It is thus extremely important for the good of the community that providers develop well-honed diagnostic assessment skills in order to identify and assist both victims and perpetrators. Healthcare providers may think, "There is nothing I can say or do to help." Yes, there is! Health professionals can break the cycle of domestic violence by providing opportunities for patients to discuss violence and by making appropriate referrals for both victims and perpetrators. Healthcare providers must realize that ignoring domestic violence is essentially an act of collusion with the perpetrator and is not a neutral action. The price of not intervening may be preventable death, serious injury, or persistent mental and physical health problems. One general practitioner reported that he found that wearing a button stating his personal opposition to domestic violence dramatically increased his patients' willingness to discuss the issue. For reasons of safety, the issue of domestic violence should not be raised with a perpetrator without the consent of the victim. It is important to keep full clinical records in these complex situations, noting clinical reasons for actions taken. Confidentiality issues are especially difficult when the victim continues to be at risk but does not want the provider to raise the issue of domestic violence with the perpetrator and does not want police intervention. Forcing interventions on unwilling patients is a violation of the ethical principle of respect for patient autonomy. Victims may prohibit intervention by healthcare professionals because they fear (often with justification) that it will make their situation worse. The provider may be able to do no more than offer support and education for victims until the victims themselves judge that the time is right to make a move. The following list of "Things to Say that Are Very Helpful to a Victim," is from Sarah Buel's "The Dynamics of Family Violence:"
A. HOW TO CONDUCT A DIAGNOSTIC INTERVIEW Use your " RADAR : R outinely screen all patients A sk direct questions. D ocument your findings. A ssess patient safety and that of the children.
All healthcare providers need to be alert to the possibility of domestic abuse in patients of every age, race, gender and socioeconomic group, and need to screen routinely for potential domestic violence. Healthcare providers should be alert for signs and symptoms of family violence, such as: • Delay in seeking care • Missed appointments • Vague or inconsistent explanation of injuries • Nonspecific somatic complaints • Depression and social isolation • Substance abuse
During the appointment, be aware of lack of eye contact and/or an intimate partner who is reluctant to leave the patient alone with the healthcare provider. Victims of abuse may appear fearful, anxious, withdrawn, angry, unresponsive or afraid to talk openly. Suicide attempts may be directly related to intimate partner violence. During the physical examination, look for injuries on many areas of the body, especially the face, throat, neck, chest, abdomen and genitals. Note any bruises, burns or wounds shaped like objects such as teeth, hands, belts, rings, or cigarette tips. Note any pain from touching. Be alert for puncture wounds, fractures and dislocations, scars on the vulva or rectum or any unexplained vaginal or anal bleeding, particularly in older people. Be aware that the victim may wear a glove or sock to conceal a scalded hand or foot. Accurate, thorough documentation of the patient's injuries is essential in cases of suspected abuse, because it can serve as objective, third-party evidence useful in legal proceedings. For example, medical records can help victims obtain a restraining order to qualify for public housing, welfare, health and life insurance and immigration relief. To be admissible in a court of law, medical documentation should include the following (Isaac & Enos, 2001): • Photographs of the injuries, taken during the initial examination. • Body maps, which document the extent and location of the injuries. • Description of the patient's demeanor (crying, angry, agitated, upset), including a record of the patient's comments about how the injuries occurred. The patient's own words should be set off in quotation marks or identified by such phrases as "the patient states" or "the patient reports." • Any description in which the patient identifies the abuser, such as "my boyfriend kicked me." • The time of day when the patient is examined and, if possible, how much time elapsed since the injuries occurred. For example, "patient says that last night his wife hit him with a shoe." • Legible handwriting. Too often, doctors' or nurses' poor handwriting on medical records makes the documentation inadmissible as evidence. Health professionals should avoid any phrases - such as "patient claims" or "patient alleges" - that cast doubt on the patient's veracity. Also avoid legal terms such as "alleged perpetrator" or "assailant." Do not use conclusive terms such as "assault and battery" or domestic violence" in documenting a case; let the factual information in the record speak for itself. B. SCREENING QUESTIONS FOR VICTIMS • Can you think of a time when your partner grabbed you or prevented you from leaving a room? • Can you think of a time when your partner pushed or shoved you? • Can you think of a time that your partner hit you? • Does your partner manipulate you to have sex if you don't want to? • Has your partner ever forced sex on you? • Are you put down or criticized? • Do you ever feel you just can't do anything right? • Do you spend a lot of time trying not to upset your partner? • Are you afraid of your partner? • Has your partner restricted you from doing what you want (such as spending time with family or friends, taking a job, engaging in a hobby outside the home)? • Do you have any money of your own to spend? Who handles the family finances? Questions NOT to ask: • Why don't you just leave him/her? • What did you do to make him/her so angry?
• SCREENING QUESTIONS FOR PERPETRATORS Perpetrators also need help, although their behavior is much less likely to elicit compassion or understanding. Few perpetrators identify domestic violence as their problem. They tend to minimize their violence or deny it altogether, and their behavior is notoriously difficult to change. The majority of those who do present are in a situation of crisis. They may have been directed by a court to attend a rehabilitation course, or their partner may be threatening to leave or have already left the relationship. Other clinical situations that may alert the provider to the possibility of partner abuse include drug- and alcohol-related problems, stress-related situations and depressive illness, a past history of childhood abuse or any new relationship where stepchildren are involved. In managing these time-consuming and often stressful consultations, consideration for the safety of victims and children must be paramount.
D. HELP FOR BATTERERS Perpetrator programs are designed to help batterers change their behavior and to develop respectful, non-abusive relationships. The emphasis is on taking responsibility for violent and abusive behavior, without minimizing it or blaming others. Perpetrators learn that they are in control of their own behavior and can choose not to be violent. It is important that they understand the impact of violence and abuse on their partner and their children. They learn different, non-abusive ways of dealing with difficulties in intimate relationships. Changing behavior is a long-term process, especially for someone long habituated to the use of violence and other forms of abuse. Batterers are most frequently motivated to change their violent behavior when they are brought to recognize its destructive impact on their children. A useful approach to take with some perpetrators is to explain how persistent fear and threats of violence can adversely affect physical, emotional, behavioral, cognitive and social aspects of a child's development. Domestic violence has been a fact of life for millennia and we should not be overly disheartened by the difficulty of bringing about change. Behavior is difficult to alter, and relapse into previous damaging patterns of interaction is common. The role of healthcare professionals is to be fully informed, clear in understanding the destructive nature of domestic violence, and to be available over time to facilitate change for perpetrators and victims. Equality wheel
SAFETY TIPS FOR VICTIMS WHO LEAVE THEIR ABUSER 1. Have an escape plan: • The best time to leave is during the "honeymoon" phase, when violence is at a minimum. Remember that the violence escalates considerably when the victim leaves. The abuser is also least likely to suspect it during this time. • Keep extra money in a safe place. • Make copies of important papers (i.e., insurance forms, birth certificates, etc.) and house and car keys. Leave the originals! • Keep these copies and a suitcase packed with necessities at a friend's house. • Confide in a neighbor, friend, or relative, asking them to be available for temporary assistance on short notice. Select the least obvious person . If needed, contact the 24-hour Domestic Violence Hotline to receive help with shelter. • Victims with children should take the children with them, to prevent their being abused or held hostage by the abuser. 2. Take what you need: When you leave , try to take as many of the following items as you can. You may not be able to go back for these things later:
You may take anything that belongs to you alone and anything that belongs to you and your partner together. You can withdraw money you have in a joint bank account with your partner. You may not take anything that belongs only to your partner and you may not destroy property that belongs to both of you. 3. When you have moved: • Alter your routine and travel routes. • Be alert to the possibility of being followed. • Do not go to familiar shopping places or social spots. • Consider renting a post office box for your mail or using the address and phone number of a friend. • If possible, change your working hours and if necessary, the school or daycare your children attend. • Inform your boss and the children's school of the situation, making sure they understand that your children are not to be released to anyone except you. (Until one parent gets a temporary custody order, each has equal rights to the children.) • If there is a court order in place, train the children to call 911 to report any violations. • You may access www.ncadv.org, the website of "The National Coalition Against Domestic Violence", to print out a safety plan. F. LEGAL PROTECTION FOR VICTIMS OF DOMESTIC VIOLENCE Florida law (741.30, F.S.) provides for the issuance of an injunction for protection for victims of domestic violence or persons who have reasonable cause to believe they are in imminent danger of becoming victims of domestic violence. (Helpful hints: Provide as much proof as possible (e.g., pictures of injuries, medical records, witnesses of abuse, etc.). Such persons must file a petition for an injunction for protection in the circuit where they or the respondent reside or where the domestic violence occurred. There is no residency requirement and no fee. As determined by the court, an injunction for protection can:
• Order the abuser not to commit any acts of violence against their partner, their children, or others living with them. • Order the abuser to be barred from any contact with the victim. • Order the abuser to leave the home they share with the victim. • Grant temporary custody of any children to the victim. • Order the abuser to go to counseling. • Order the abuser to give any guns to the police.
An injunction for protection may be obtained by: • A spouse or ex-spouse of the abuser. • A relation by blood or marriage of the abuser. • Anyone who has lived as a family with the abuser. • Anyone who shares a child with the abuser.
Information on obtaining an injunction for protection may be found by calling any of the following numbers. Broward County Women in Distress (954) 761-1133 Miami-Dade County Domestic Violence Intake Unit (305) 547-3170 North Dade Justice Center (305) 354-8707 Joseph Caleb Center (305) 636-2255 South Dade Government Center (305) 252-5870 Monroe County Domestic Abuse Shelter (305) 743-4404 Palm Beach County Aid to Victims of Domestic Assault (561) 265-2900 YWCA Harmony House (561) 640-9844 To make the most effective use of an injunction for protection, victims of domestic violence must:
IV. ELDER AND CHILD ABUSE
Ask the person who brought the child in how and when the injury occurred. A story that doesn't match the extent of the injury should arouse suspicion, as should a delay in seeking care or conflicting accounts by the people involved. Basic questions to ask are: What was the date and time of the injury and when was it first noted? Where did it occur? Who witnessed it? What was happening prior to the injury? What did the child do afterward? How long did the caregiver wait before seeking treatment for the child? If the child can talk, get his or her account of the incident, as well. If you suspect an intentional injury, examine the child completely, undressing them to assess for hidden bruises or marks.
Media reports give the erroneous impression that elder abuse occurs primarily in nursing homes, but research indicates that most abuse and neglect of elders occurs at home. Most of the time, the perpetrators are spouses or family members (National Center on Elder Abuse, 2002). The abuse may be intentional or unintentional, due to lack of knowledge or lack of ability or desire to provide proper care. Families stressed by illness, unemployment, alcohol and/or drug use are more likely to experience violence. This is particularly true with elder abuse, especially if the older person is frail or mentally impaired, the caregiver is ill prepared for the task, or if needed resources are unavailable. Adult children who abuse their parents frequently suffer from mental and emotional disorders, alcoholism, drug addiction, and/or financial problems that make them dependent on the parents for support. V. FLORIDA REPORTING REQUIREMENTS Florida is 1 of 10 states having participated in the Family Violence Prevention Fund's healthcare initiatives since 1995. These initiatives have resulted in important policy changes concerning reporting domestic violence, training reforms, public education, and outreach into diverse and underserved communities. Florida now requires health practitioners to take a two-hour domestic violence education course as part of every third relicensure or recertification Florida statute 790.24 requires healthcare providers knowingly treating anyone suffering from a gunshot wound or life-threatening injury indicating an act of violence, or receiving a request for such treatment, to report the same immediately to the sheriff's department of the county in which said treatment is administered or request for treatment is received. A healthcare provider willfully failing to report such treatment or request for treatment is guilty of a first-degree misdemeanor. Florida law classifies people with disabilities who may be unable to adequately provide for their own care and protection as vulnerable adults . A vulnerable adult is defined (Chapter 415, F.S.) as someone "age 18 or older whose ability to perform the normal activities of daily living, and/or to provide for his or her own care or protection, is impaired due to a mental, emotional, long-term physical, or developmental disability or dysfunctioning, or brain damage, or due to the infirmities of aging". All healthcare professionals, including employees of long-term care facilities, are required to report suspected abuse, neglect or exploitation of such persons to the Florida Abuse Hotline of the Department of Children and Families: 1-800-962-2873. Chapter 39 of the Florida statutes mandates that any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned or neglected by a parent, legal custodian, caregiver or other person responsible for the child's welfare shall immediately report such knowledge or suspicion to the Florida Abuse Hotline (see phone number listed above). All healthcare professionals are required to provide their name to the hotline staff. The name of the person reporting shall be entered into the record of the report, but shall be held confidential. The healthcare professional should discuss mandatory reporting requirements with those involved prior to screening. |
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Child and elder abuse are serious social problems in this country, and frequently these cases first come to light in EDs or medical offices. 872,000 children in the United States were victims of child abuse or neglect in 2004. Multiple fractures, spiral fractures and fractures in various stages of healing should raise flags; so too, should abdominal bruises or serious abdominal injury in the absence of accidental trauma. Also be alert for retinal hemorrhages, which could indicate shaken baby syndrome.
Reports to Adult Protective Services (APS) agencies of domestic elder abuse increased 150 percent between 1986 and 1996, even though the older population increased by only 10 percent (Administration on Aging, 2001). Older women in abusive situations are the least likely to report the abuse, primarily due to social and cultural values.