Domestic Violence Education for Kentucky Nurses
Online Continuing Education Course
MANDATORY KENTUCKY NURSING CEU. This 3-hour domestic violence CE course covers health effects on adult and child victims, legal remedies for protection, lethality and risk issues, model protocols for addressing domestic violence, community resources and victim services, and KY reporting requirements.
Course Price: $30.00
Contact Hours: 3
Choose a profession below:
This course fulfills the Kentucky Board of Nursing requirement of 3 hours of continuing education in domestic violence for nurses.
Domestic Violence Education for Kentucky Nurses
Copyright © 2017 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this continuing education course, you will have increased your understanding of the impact of domestic violence and the role of the Kentucky nurse in identifying and responding to patients presenting with known or suspected domestic violence signs and symptoms. Specific learning objectives include:
- Describe who is affected by domestic violence.
- Discuss the healthcare implications of domestic violence.
- List common risk factors and lethality issues.
- Identify the dynamics associated with the different types of domestic violence.
- Recognize the signs and symptoms of domestic violence.
- Discuss appropriate documentation in cases of suspected domestic violence.
- State Kentucky’s reporting requirements for domestic violence.
- Describe actions to protect victims.
- Explain a model protocol that addresses domestic violence.
- Identify community resources and victim services.
TABLE OF CONTENTS
- Who Is Affected by Domestic Violence?
- Health Effects of Domestic Violence
- Risk Factors and Lethality
- What Do the Dynamics of Domestic Violence Look Like?
- Understanding Perpetrators and Victims
- Assessment, Documentation, and Treatment
- Reporting Requirements in Kentucky
- Caring for Victims of Abuse
- Community Resources and Prevention
On September 14, 2015, 26-year-old Marilyn Stanley of Union, Kentucky, was brutally beaten and scalped by her ex-boyfriend and then attacked by a dog at his command. Before releasing her, the ex-boyfriend forced her to look in a mirror while he ridiculed her appearance. Marilyn, a young mother, lost most of her scalp as well as one of her ears during the attack (CNN, 2015).
This is but one example of recent domestic violence in the United States, where 1 in 3 women and 1 in 4 men are victims of domestic violence (Black et al., 2011). Viewed as a national public health problem, domestic violence is a crime in all 50 states. Other crimes that may be related to domestic violence include:
- Criminal coercion
- Unlawful imprisonment
- Sexual assault, rape
- Manslaughter, murder
The term domestic violence refers to physical, verbal, psychological, sexual, or economic abuse (e.g., withholding money, lying about assets) used to exert power or control over someone or to prevent someone from making a free choice. According to the U.S. Department of Justice (2010), “This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.” Rape, incest, and dating violence are all considered to be forms of domestic violence.
Domestic violence in Kentucky is defined as an assault against a family member by a family member. Kentucky law defines family member as a current or former spouse, a parent, a grandparent, a child, or a stepchild. It also defines any person living in the same household with a child as a family member if the victim is a child.
The law includes persons who have a child or children together, even if unmarried, as well as unmarried couples who cohabitate or have done so in the past. The unmarried couple’s children are included in this definition, as are persons who currently live or once resided together with the alleged victim (KRS 403.720).
In addition, the law protects vulnerable adults (age 18 and older) who have mental or physical dysfunction.
Many victims of elder abuse also fall within the Kentucky domestic violence laws when the victim and the abuser are related (KRS 209).
In 2016, the law in Kentucky was amended to include current or former unmarried couples, dating violence, sexual violence, and stalking as forms of domestic violence that allow victims to be granted protective orders (KRS 456.010–456.180) (Kentucky Court of Justice, 2016).
DOMESTIC VIOLENCE TERMINOLOGY
Various other terms are used to refer to domestic violence:
- Intimate partner violence (IPV) is a more specific term often used when referring to harm to a current or former partner or spouse.
- Domestic abuse is a term that highlights the nonphysical components of an abusive situation; these include psychological or emotional abuse, threatening, and stalking, as well as neglect or financial exploitation, particularly of older adult family members.
- Family violence is a term also used to describe abusive domestic situations because children in the family may be affected, either as witnesses of violence and/or as victims themselves.
WHO IS AFFECTED BY DOMESTIC VIOLENCE?
Domestic violence may occur in the lives of persons of all ages, cultural/ethnic/religious groups, genders, and social classes. Intimate partner violence is one of the most common but least reported crimes, so it is impossible to know the actual incidence and prevalence. Feelings of shame, fear, and hopelessness often prevent victims from seeking protection and support. Many abused women do not report domestic violence to their physicians or to anyone else. However, the statistics available confirm that the problem is pervasive and alarming.
Domestic violence is an ongoing and critical problem in Kentucky.
- According to statistics compiled by the Kentucky State Police (2015), the Department for Community-Based Services investigated 20,481 allegations of domestic violence.
- People seeking domestic violence protective orders filed 23,685 petitions in fiscal year 2014. The Kentucky Domestic Violence Association received 24,497 domestic violence–related calls and 24,628 calls for information and referrals.
- In addition, 102,294 adult protection service calls were made to the toll-free reporting hotline, and 18,685 civil cases were filed.
- Kentucky was able to provide emergency shelter to 3,309 victims during the year 2015, but turned away an additional 1,195 due to lack of available housing.
The economic impact of intimate partner or domestic violence that accompanies the personal and emotional impact is clear. This economic impact affects the victim, the employer, and the community. Research indicates that victims of domestic violence in the United States lose 8 million work days, or the equivalent of more than 32,000 full-time jobs, annually. Individuals may develop strained relationships with employers due to poor job performance, tardiness, and absenteeism (CDC, 2015).
Domestic Violence among Women
Victims of domestic violence are usually women and children. Perpetrators of domestic violence are generally, though not always, men. According to the Centers for Disease Control and Prevention (CDC), more than 12 million women and men are victims of intimate partner violence over the course of a year. In 2007, IPV resulted in 2,340 deaths and accounted for 14% of all homicides. Of these deaths, 70% were females and 30% were males. Many victims do not report IPV to police, friends, health professionals, or family, so these statistics underestimate the problem (CDC, 2012).
Teens and Dating Violence
Teen dating violence is another form of IPV that is disturbingly common among high school students and can result in serious long-term and short-term effects. The nature of dating violence can be physical, emotional, or sexual. Dating violence can also include stalking and can take place in person or electronically.
As with adult victims of IPV, many teens do not report their victimization, but according to a 2013 survey, approximately 10% of high school students reported being physically victimized by a boyfriend or girlfriend and another 10% reported sexual victimization from an intimate partner (Kann et al., 2014).
A CDC survey discovered a relationship between adult victims of sexual or intimate partner violence and early exposure to some form of violence between the ages of 11 and 17. This relationship was identified in 23% of females and 14% of males who ever experienced rape, physical violence, or stalking as adults (CDC, 2016b).
Those who harm their dating partners are more likely to be depressed and more aggressive than their peers. Other characteristics of abusive dating partners include:
- Trauma symptoms (irritability, anxiety, anger, difficulty concentrating, or insomnia)
- Exposure to harsh parenting
- Exposure to inconsistent discipline
- Lack of parental supervision and warmth
- Belief that using dating violence is acceptable
- Alcohol use
- Behavioral problems in other areas
- Having a friend involved with dating violence
Consequences of teen dating violence may include:
- Depression and anxiety
- Tobacco, alcohol, and drug use
- Antisocial behaviors
- Thoughts about suicide
- Continued victimization in college
Domestic Violence among Older Adults
Kentucky does not have an elder abuse law. Instead, the law (KRS 209.020, 209.030, 209.050, and 209.990) provides for protection of adults age 18 and over “who because of a mental or physical dysfunction cannot carry out the activities of daily living or protect themselves from others who may abuse, neglect, or exploit them” (RAINN, 2016).
Knowledge of elder abuse is thought to be about 20 years behind the fields of domestic violence and child abuse, and there is an urgent need for research on the topic (NCEA, 2016). Abuse of older adults may be missed by professionals who work with these patients because of a lack of training in detecting abuse. Abuse may go unreported by the victims themselves because they may be unable physically or cognitively to seek help, they do not want to get the abuser in trouble, or they fear retaliation.
Various studies on elder abuse present different findings, but the most common type of elder abuse is financial, followed by neglect, physical abuse, and sexual abuse.
According to the National Center for Elder Abuse, the most common physical findings of physical abuse among older adults include:
- Dental problems
- Head injuries
- Pressure ulcers
- Chronic pain
- Sexually transmitted infections
- Poor nutrition
- Poor hydration
- Sleep problems
- Increased susceptibility to new illnesses
Domestic Violence among Minority Racial and Ethnic Groups
Domestic violence is a crime without cultural boundaries. It affects people from all walks of life regardless of race, religion, or economic class. The desire or ability to report the crime and access services may also be affected by the person’s culture. Therefore, it is essential for health professionals to consider cultural differences when working with immigrant and diverse communities in order to provide appropriate and sensitive services (NIJC, 2013).
Some cultures believe that the family is the only appropriate forum for dealing with domestic violence, and outside interference is not encouraged or accepted. Other ethnicities may even resist acknowledging that domestic violence exists as a problem. It can be challenging to assist victims who do not understand that help is available. Language barriers and lack of knowledge of legal rights or resources can also be an obstacle to seeking help.
The predominant immigrant communities in Kentucky are Asian and Hispanic, with Asians and Latinos making up 4.8% of the population as of July of 2015, according to the U.S. Census Bureau (2016). A recent study demonstrated that the Asian population nationwide is less likely to access professional services and tends to use informal means of support such as family and friends. Asian victims seem to utilize formal help less than victims of other racial groups (Cho, 2012).
Hispanics now comprise 16% of the national population and are the largest ethnic minority in the United States. Studies show that although IPV occurs at a similar rate in this population as it does in other ethnic groups, these victims are less likely to report the abuse or seek help. Possible contributing factors are that the victims may not trust the police, fear deportation, feel shame or guilt, or have a history of child victimization. In addition, the victims may not understand what type of help is available or how to access services.
African Americans comprise 8.3% of the population in Kentucky. Complex issues of racism, in combination with sexism, may contribute to increased prevalence of domestic violence in the African American community. Black women are as much as three times more likely to die from domestic abuse as white women, making it one of the leading causes of death for black women between the ages of 15 and 35. Although the most important risk factor for femicide is prior domestic violence, men who murder their domestic partners are likely to be unemployed, and the unemployment rate is higher in African Americans than in other races (Sabri, 2014).
Black women also under-report domestic violence more than women from other communities (Ingram, 2017). One impediment to reporting domestic violence faced by black women is that they are less likely to trust potentially racially biased law enforcement agents and the legal system than are their white counterparts. African American communities may be more likely to rely on a faith-based social system and prefer to keep their problems private. In 2013, 92% of black, female homicide victims knew their killers, and 56% were wives, domestic partners, ex-wives, or girlfriends of the offenders (Violence Policy Center, 2015).
U VISA and T VISA
The U visa is a nonimmigrant visa that was created in 2000 with the passage of the Victims of Trafficking and Violence Protection Act (including the Battered Immigrant Women’s Protection Act). It is a unique visa for victims of crimes who have suffered substantial mental or physical abuse and are willing to assist law enforcement in the investigation or prosecution of the criminal case. It was developed with the intent to strengthen the ability of law enforcement to investigate and prosecute certain types of cases.
Victims who are granted a U visa are given temporary legal status and work eligibility in the United States for up to four years. This program helps law enforcement agencies assist many victims of crimes who would otherwise not be served.
The T visa is a similar plan in which qualifying victims of trafficking, along with approved family members, may reside in the U.S. for approximately four years if they comply with criminal justice system requests.
Sources: U.S. DHS, 2016, 2014.
Domestic Violence and Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and Intersex Persons
The national Violence Against Women Survey summarizes the second year of data collection from the National Intimate Partner and Sexual Violence Survey (Breiding et al., 2011), in which 21.5% of men and 35.4% of women who live with a same-sex partner reported intimate-partner physical violence in their lifetimes.
A Massachusetts survey reported a lifetime prevalence of domestic violence among 34.6% of transgender persons (Ard & Makadon, 2011). In 2012, the National Coalition of Anti-Violence Programs reported the highest yearly total of LGBTQI intimate partner homicides ever recorded. Kentucky was one of the 20 states that participated in the survey.
Persons who identify as lesbian, gay, bisexual, transgender, queer/questioning, or intersex (LGBTQI) do not often access services or report to the police. There are many reasons they do not seek help, such as:
- An LGBTQI victim may fear that the abuser will reveal his or her sexual orientation or biological gender to family, friends, or coworkers.
- Abusers may threaten to reveal an infected person’s positive HIV status to others or to transmit HIV to the victim if he or she is HIV negative.
- These individuals fear institutional discrimination and homophobic or transphobic care providers.
- A transgender person may not have undergone sexual reassignment surgery and may avoid a physical exam by a clinician that might include observation of his or her genitals.
Law enforcement authorities may not recognize same-sex individuals as intimate or domestic partners and may have a difficult time determining the primary abuser or that the assaultive behavior is actually a domestic crime. Access to services is severely limited by lack of shelters that serve male victims. Sensitivity to the needs of this group is paramount to effecting social change and helping victims receive needed assistance (Sanctuary for Families, 2014; NCAVP, 2012).
Domestic Violence and the U.S. Military
Military regulations require that all military officials report any suspicion of family violence to a Family Advocacy agent. Officials include commanders, first sergeants, supervisors, medical professionals, teachers, and police officers. If the abuser is a military member, the military justice system will be implemented. Family Advocacy conducts an investigation, intervenes, and provides treatment. They may substantiate the abuse, but if there is insufficient legal evidence, there may be no punishment for the abuser. There is no confidentiality in the military, as there is with civilian advocacy, and any pertinent statements that are made during interactions with Family Advocacy are recorded and passed on to the legal sector.
If there is sufficient legal evidence, the military justice system may reprimand the abuser or mandate extra training or counseling. Reprimands can be verbal or written. Written reprimands are recorded and can negatively affect the subject’s career. In many cases, the subject is required to be separated from his or her spouse and required to be housed in barracks, if available, until an investigation has been completed and the subject may be issued a no-contact order with the victim.
Military spouses may decide not to report the abuse for all of the same reasons that civilian victims do not report, and they may also hesitate because the accusation may negatively impact their spouse’s career. In fact, a military member who is a domestic abuser is 23% more likely to be discharged than a nonabuser, and if not discharged, is likely to be promoted more slowly than a nonabuser. The federal government provides limited financial protection (up to 36 months) to the abused spouse if the military member is discharged for the abuse of a spouse or dependent child (Powers, 2016).
HEALTH EFFECTS OF DOMESTIC VIOLENCE
Domestic violence has an enormous impact on the health of those who are affected as well as on the healthcare system.
The 2014 National Violence Against Women Survey summarizes the second year of data collection from the National Intimate Partner and Sexual Violence Survey. It found that 1 in 4 women and 1 in 7 men aged 18 and older in the United States experience severe physical violence by an intimate partner in their lifetime. Nearly 15% of women and 4% of men have been injured as a result of acts of domestic violence that included rape, physical violence, and/or stalking by an intimate partner in their lifetime (Breiding et al., 2011).
Injuries sustained during episodes of violence are only part of the damage to victims’ health. Physical and psychological abuse are related to other adverse effects, including complaints such as:
- Back pain
- Pelvic pain
- Gastrointestinal disorders
- Gynecological disorders
- Obstetrical problems
- Sexually transmitted infections
- Central nervous system disorders
- Heart or circulatory conditions
Intimate partner violence is also linked to mental health problems, including:
- Antisocial behavior
- Low self-esteem
- Inability to trust men
- Fear of intimacy
- Posttraumatic stress disorder
- Substance abuse
- Risky sexual activity
(Dillon et al., 2013)
Although 77% of women suffer from a chronic health condition in their lifetimes, the percentage increases to 81% for women who have experienced domestic violence and 88% for women who have experienced sexual abuse (Verizon Foundation, 2013).
Chronic pain and depression have many causes other than IPV, but either symptom should alert healthcare professionals to ask about violence in the home or intimate partner relationships, both past and present. A key finding in the Verizon study was that only 20% of participants reported that healthcare professionals had queried them about violence in their lives.
When physicians and nurses did ask patients about abusive behaviors, the most commonly asked questions were, “Has anyone close to you made you feel afraid for your own safety?” and “Has your partner ever physically hurt you?” The survey results reported that younger women, ages 21 to 44, were most likely to be asked directly about abuse, as compared to women over 44 years of age, and that nearly two thirds of the women who had experienced abuse reported that they would have wanted their physician or nurse to have asked them about domestic violence (Verizon Foundation, 2013).
HEALTH EFFECTS ON CHILDREN
Children who are subjected to domestic violence develop problems such as attachment disorder, depression, anxiety, and oppositional defiance disorder. A violent environment will have the greatest adverse effects on the brains of the youngest children, even infants. This is because the developing brain of a child is highly sensitive, and the chronic state of fear and stress that these children experience prevents the brain from developing normally. Instead, the brain is influenced adversely by abnormal patterns of neurological activities and brain chemicals (Child Welfare Information Gateway, 2015).
The Adverse Childhood Experience (ACE) Study, published in 2009, investigated the association between childhood maltreatment and later-life health and well-being (CDC, 2009). The ACE Study findings suggest that child maltreatment experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. The more adverse childhood experiences that were experienced by an individual, the greater the risk of developing alcoholism, chronic obstructive pulmonary disease (COPD), depression, illicit drug use, intimate partner violence, sexually transmitted infections, criminality, and smoking.
(See also “First Impressions: Exposure to Violence and a Child’s Developing Brain,” listed in the “Resources“ section at the end of this course.)
RISK FACTORS AND LETHALITY
Common Risk Factors
The National Institutes of Health published a systematic review of risk factors for IPV (Capaldi et al., 2012). They include:
- Low self-esteem
- Age range in adolescence and young adulthood
- Unemployment and low income
- Minority group membership
- High levels of acculturation stress
- Financial and work-related stress
- Lack of parental support and/or monitoring in adolescents
- Adolescent involvement with aggressive peers
- Social isolation
- Conduct problems
- Depression and irritability
- Substance use
- Low relationship satisfaction
- Childhood victimization
- Exposure to interparental violence
- Alcohol use
Although domestic violence is found in all walks of life, those who live in poverty face additional challenges. The CDC (2016c) lists poverty as a risk factor for intimate partner violence. Poverty damages health and well-being in countless ways; exposure to domestic violence is just one. When IPV and persistent poverty intersect, they limit coping options. Both poverty and IPV lead to stress, feelings of powerlessness, and social isolation, which combine to produce posttraumatic stress disorder, depression, and other emotional difficulties.
Such women face risks from the batterer and risks resulting from their poverty.
- Risks from the batterer include physical injury; threats and loss of security, housing, and income; and potential loss of their children.
- Risks from poverty include food insecurity, lack of access to health insurance and healthcare, possibly racism, unsafe neighborhoods, and poor schools for their children.
The double jeopardy of poverty and IPV challenges abused women and the healthcare and social service professionals responsible for protecting them. Intervening to stop the violence is only the first step. Issues of income, housing, and healthcare—both mental and physical—must also be addressed. For instance, research shows that domestic violence is a primary cause of homelessness for women and families. A study in Massachusetts showed that 63% of homeless women were survivors of IPV (NAEH, 2014).
To remedy this problem, Kentucky launched a housing program in 2011, which is now managed by the Kentucky Coalition Against Domestic Violence (KCADV). The coalition also provides the Economic Empowerment Program, which includes financial education, credit counseling, tax preparation, and the opportunity to open individual development accounts to help survivors save toward a specific goal (KCADV, 2016).
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 poorly prepared for the task, or 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. These families respond to tension or conflict with violence because they have not learned any other way to respond.
IPV often begins or escalates during pregnancy, making pregnancy an especially dangerous time for women in abusive relationships. Any type of abuse during pregnancy increases the risk of health problems for the woman and the unborn child because a pregnant woman is particularly vulnerable both physically and emotionally. Trauma from physical abuse can cause a woman both acute injury and increase her risk for an obstetrical emergency, preterm birth, complications during labor, or miscarriage later in the pregnancy (NDVH, 2013).
The most recent data from the National Violent Death Reporting System revealed 94 counts of pregnancy-associated suicide and 139 counts of pregnancy-associated homicide in a multistate sample of the United States during the years 2003 to 2007. Intimate partner conflict was associated with 54.3% of the pregnancy-associated suicides and 45.3% of the pregnancy-associated homicides. These deaths confirm the need to evaluate IPV with pregnancy-associated violent death (Palladino, 2011).
Battering can lead to adverse effects on both the mother and the baby. The mother may experience high blood pressure or edema, vaginal bleeding, kidney or urinary tract infection, and posttraumatic stress disorder (Silverman et al., 2006). The stress of abuse may also cause pregnant women to continue such unhealthy habits as smoking and drug or alcohol use. Abused women are also at high risk for postpartum depression, which can interfere with breastfeeding and affect their relationships with their babies and other children as well as with other adults (Kendall-Tackett, 2007).
Miscarriage, low birth-weight, or other injury may occur in the developing fetus, and a study by Lannert and colleagues (2014) suggests that a fetus whose mother experiences violence can be affected by her elevated cortisol levels. Cortisol is a neurotoxin, and babies who have a high cortisol exposure in utero may develop nightmares, intolerance to noise and bright lights, and emotional problems later in life. In other words, a baby whose mother is a victim of domestic violence can suffer consequences of the abuse even before being born.
According to research, women with a disability are more likely to experience IPV than those without a disability. In fact, 37.3% of women with a disability reported experiencing some form of IPV during their lifetime as compared to 20.6% of women without a disability (CDC, 2012).
Having a disability limits a woman’s options for escaping or resolving the abuse. For example, if an abusive partner withholds needed equipment, such as a wheelchair or assistance with dressing or getting out of bed, this prevents access to programs that could help end the abuse (Nosek, 2001). Unemployment further disadvantages women with disabilities, decreasing their chances of being able to break the cycle of violence (Smith, 2008).
Women living with HIV also can be at increased risk for IPV. According to the National Women’s Health Information Center, many women infected with HIV report emotional, physical, or sexual abuse at some time after their diagnosis.
Risk of Lethality
Without any sort of intervention, abuse tends to escalate. While not all abusers kill and there are no perfect predictors of time and place, research has revealed some patterns of escalation in domestic violence. The time of separation—when an abuse victim leaves the abuser and just afterward—presents the greatest threat to the abuser’s ability to maintain power and control.
Risk factors for domestic violence femicide or homicide include:
- Previous nonfatal strangulation (7 times higher)
- Separation from the abuser
- Pregnancy (3 times higher)
- Perpetrator substance or alcohol abuse (problem drinking is associated with a twofold increase of completed or attempted femicide)
- Access to firearms
- Use of firearms during previous incidents of domestic violence
- Perpetrator unemployment
Incidents in which a family member kills a domestic partner or other family members and then kills himself are fortunately rare, but awareness of risk factors for lethality in a relationship is important.
According to data gathered by the CDC from 408 such homicide-suicide cases, 91% of the perpetrators were men and 88% used a gun. There was a history of intimate partner violence in 70% of the cases, although only 25% of prior domestic violence appeared in the arrest records. The point of separation was acknowledged as a vulnerable period, and risk factors for homicide-suicide were identified as:
- Prior domestic violence
- Access to a gun
- Threats with a weapon
- Stepchild in the home
- White, non-Hispanic male
- Possessively jealous
- Substance abuse
- Family stressors
ACCESS TO GUNS
Studies have demonstrated that the risk of homicide to a victim of domestic violence is five times higher when the abuser has access to a gun (Campbell et al., 2003) and that incidents of homicide are reduced when persons under a restraining order are prohibited from purchasing a firearm (Sorenson, 2006). Federal law prohibits individuals who have been convicted of domestic violence misdemeanors or are subject to domestic violence protective orders from possessing guns or ammunition.
In spite of the overwhelming evidence that access to firearms increases the risk of homicide in domestic violence cases and federal laws that disallow abusers to retain or purchase firearms and ammunition, the state of Kentucky does not prohibit convicted domestic violence abusers from possessing guns, nor does it require that they surrender firearms or ammunition or require that guns be removed even when they are discovered at the scene of a domestic violence incident. In fact, Kentucky law does not “operate as a ban on the purchase or possession of firearms or ammunition” by a defendant who has a restraining order because of a conviction for or a guilty plea to stalking (Ky. Rev. Stat. Ann. § 508.155(6)).
Although federal gun laws provide many loopholes for perpetrators to retain firearms, Kentucky state laws allow individual courts options to protect domestic violence victims from gun violence. These laws include:
- The Kentucky Justice and Public Safety Cabinet must make a reasonable effort to notify the person who obtained a domestic violence protective order if that person requested to be notified should the person subject to the order attempt to purchase a firearm. This requirement only applies if the person who sought the protective order requests such notification (Ky. Rev. Stat. Ann. § 237.100(1), (2)).
- A court or agency may impose, as a condition of pretrial release, an order prohibiting the person from using or possessing a firearm. This pertains to persons who were charged with sexual violations or a domestic violence protective order (Ky. Rev. Stat. Ann. § 431.064).
- Kentucky law may suspend a license to carry a concealed deadly weapon if the licensed person is subject to a domestic violence order or emergency protective order (Ky. Rev. Stat. Ann. § 237.110(13)(k)).
(Law Center to Prevent Gun Violence, 2016)
WHAT DO THE DYNAMICS OF DOMESTIC VIOLENCE LOOK LIKE?
While domestic violence can manifest in a variety of manners and severity, the CDC recommends using a consistent definition in order to monitor trends over time (CDC, 2016a). There are four main types of domestic violence (also called intimate partner violence):
- Physical violence
- Sexual violence
- Psychological aggression
(Breiding et al., 2015)
Research indicates that domestic violence occurs in a three-phase cycle (Walker, 2017):
- A period of increasing tension, leading to verbal and physical abuse
- Acute battering incident
- A “honeymoon” period of calm and remorse in which the abuser is kind and loving and begs for forgiveness
When stress and conflict begin to build, the cruel cycle begins again. Over time, the first two phases grow longer and the honeymoon phase diminishes.
Physical violence can be defined as “the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, slapping, punching, burning, use of a weapon, and use of restraints or one’s body, size, or strength against another person.” Physical violence can also include coercing another person to perform those acts (Breiding et al., 2015).
There are five categories of sexual violence as identified by the CDC. These include:
- Rape or penetration of the victim. The definition includes attempted rape and penetration that is drug-facilitated or forced.
- Forcing the victim to penetrate another person. This act includes alcohol- or drug-facilitated incidents.
- Unwanted penetration of the victim by the use of nonphysical methods such as verbal pressure or abuse of authority.
- Unwanted sexual contact in which the perpetrator touches the victim or forces the victim to touch the perpetrator either directly or through the clothing without the victim’s consent. The areas of the body involved in the definition include genitalia, buttocks, anus, groin, inner thigh, and breast.
- Unwanted noncontact sexual experiences, such as exposure to pornography, sexual harassment, filming or photography, and threats of sexual violence.
(Breiding et al., 2015)
Kentucky statutes 510.040, 510.050, and 510.060 describe the crime of rape, in which a person engages in sexual intercourse with another person by forcible compulsion, or engages in sexual intercourse with another person who is incapable of consent due to being physically helpless, of poor mental capacity, or a young age.
Kentucky statute 510.110 describes the crime of sexual abuse, in which a person subjects another person to sexual contact by forcible compulsion, including those who are incapable of consent due to being physically helpless, of poor mental capacity, or a young age.
Psychological aggression is defined by the CDC as “the use of verbal and nonverbal communication with the intent to harm another person mentally or emotionally, and/or to exert control over another person” (Breiding et al., 2015). This form of abuse may include name-calling, humiliation, and control over finances, transportation, and access to family and friends.
It may also include reproductive coercion, such as deliberately exposing a partner to sexually transmitted infections (STIs); attempting to impregnate a partner against her will (by damaging condoms or throwing away her birth control pills, also called birth control sabotage); threats or acts of violence if the partner does not comply with the perpetrator’s wishes concerning the decision to terminate or continue a pregnancy; as well as threats or acts of violence if the partner refuses to have sex.
Psychological aggressors may exploit vulnerabilities of the victim, such as immigration status or disabilities, or present false information to the victim with the intent of causing victims to doubt their memories or perceptions.
Researchers report that psychological/emotional (nonphysical) violence may be more difficult to endure and have more lasting effects than physical violence, particularly in middle-aged and older women. This kind of abuse appears to be more effective in controlling the victim’s behavior than physical violence because it erodes self-esteem and increases uncertainty, hopelessness, and fear (Seff et al., 2008).
The “invisibility” of nonphysical abuse serves as a barrier to reporting the abuse. Victims fear that law enforcement officers would not recognize psychological or emotional violence as a crime. Victims have reported to researchers that, “[The police] want to see the bruises and the black eye and the teeth knocked out,” and “You have no proof of it. You have nothing to show, and you can’t have them arrested” (Seff et al., 2008).
Stalking and Cyberstalking
The U.S. Department of Justice (2016) identifies several types of unwanted “stalking” behaviors that would cause a reasonable person to experience fear. Examples of behaviors that are experienced by stalking victims include.
- Receiving unwanted phone calls
- Receiving unsolicited or unwanted letters or emails
- Being followed or spied on
- Having the stalker show up at places without a legitimate reason
- Having the stalker wait at places for the victim
- Receiving unwanted items, presents, or flowers
- Having information or rumors about the victim posted on the Internet, in a public place, or by word of mouth
Although these acts individually may not be criminal, collectively and repetitively they may cause a victim to fear for his or her safety or the safety of a family member. Women are disproportionately victimized by stalking, with a prevalence of 1 in 6 women experiencing stalking in their lifetime compared to 1 in 19 men (Breiding et al., 2011).
The explosion of digital technology—cellular phones, GPS systems, the Internet, and social networking sites such as Facebook and YouTube—is abused by some, resulting in cyberstalking, cyberbullying, harassment, sexting (sharing naked images of oneself or others), and dating abuse. Collectively, these activities are known as digital abuse, which is particularly pervasive among teens (Associated Press-MTV, 2009).
Half of people ages 14 to 24 reported experiencing digitally abusive behavior, and females were more likely to have been targeted than males. Nearly 1 in 4 young people currently in a dating relationship report that their dating partner checks up on them many times each day either online or by cell phone to see where they are, whom they are with, and what they are doing. Others report that their dating partners attempt to manipulate and control them by checking the text messages on their phone without permission, demanding their passwords, or demanding that they “unfriend” former dating partners on social networks.
Although there is no universally accepted definition of cyberstalking, the term is used here to refer to the use of the Internet, email, or other electronic communications devices to stalk another person. Cyberstalking has become an all-too-common means of harassment, particularly by spurned intimate partners. Even though cyberstalking does not involve physical contact with the perpetrator, it can constitute emotional and psychological abuse.
The Stalking Resource Center recommends that victims of cyberstalking:
- Trust your instincts.
- Call the police if there is immediate danger and explain why certain actions cause fear.
- Keep a record of each contact and save all emails, text messages, photos, and other communications.
- Connect with a local advocate to discuss options and a safety plan.
- Call the National Domestic Violence Hotline.
(See “Resources” at the end of this course).
EFFECTS OF STALKING
Victims of stalking suffer from both short-term and long-term effects and are more likely than their nonvictim counterparts to experience:
- Posttraumatic stress disorder (PTSD)
- Chronic pain
- Difficulty sleeping
- Limited activity
- Poor physical health
- Poor mental health
(Black et al., 2011)
Stalking often precedes murder or attempted murder of women by their intimate partners (femicide). Researchers reported that 76% of women murdered by their former partners had been stalked by their partners in the year prior to their murder. Most women were stalked after the relationship had ended. More than half of femicide victims had reported the stalking to police before they were killed by their stalkers (McFarlane et al., 1999).
STALKING UNDER KENTUCKY LAW
KRS 508.130 defines stalking as engaging in an intentional course of conduct which:
- Is directed at a specific person or persons
- Seriously alarms, annoys, intimidates, or harasses the person or persons
- Serves no legitimate purpose
- Would cause a reasonable person to suffer substantial mental distress
According to Kentucky statute 508.140, a person is guilty of the felony of stalking in the first degree who intentionally:
- Stalks another person; and
- Makes an explicit or implicit threat with the intent to place that person in reasonable fear of:
- Sexual contact as defined in KRS 510.010;
- Serious physical injury; or
- Death; and
- A protective order has been issued by the court to protect the same victim or victims and the defendant has been served with a summons or warrant or has been given actual notice; or
- A criminal complaint that is currently pending with a court, law enforcement agency, or prosecutor by the same victim or victims and the defendant has been served with a summons or warrant or has been given actual notice; or
- The defendant has been convicted of or pled guilty within the previous five years to a felony or to a Class A misdemeanor against the same victim or victims; or
- The act or acts were committed while the defendant had a deadly weapon on or about his or her person.
According to Kentucky statute 508.150, a person is guilty of the misdemeanor of stalking in the second degree who intentionally:
- Stalks another person; and
- Makes an explicit or implicit threat with the intent to place that person in reasonable fear of:
- Sexual contact as defined in KRS 510.010;
- Serious physical injury; or
UNDERSTANDING PERPETRATORS AND VICTIMS
People outside of abusive relationships often wonder both why a perpetrator abuses and why a victim of abuse remains in such a relationship.
Why Perpetrators Abuse
Typically, abusers want power and control, and all their various behaviors are intended to achieve that end.
Although an abuser’s behavior may also arise from or be exacerbated by a mental illness, that is not usually the case; however, abusive behaviors may be complicated by substance abuse problems. Health professionals should be alert to any signs of these complicating factors when assessing high-risk individuals.
POWER AND CONTROL
A model developed by the Domestic Abuse Intervention Project in Duluth, Minnesota, known as the Power and Control Wheel, depicts the most common abusive behaviors or tactics experienced by battered women. It is characterized by the pattern of actions that a male abuser uses to intentionally control or dominate his intimate partner. These actions fall under eight primary categories:
- Using coercion and threat
- Using intimidation
- Using emotional abuse
- Using isolation
- Minimizing, denying, and blaming
- Using children
- Using male privilege (potential socio-economic advantages for persons of male gender)
- Using economic abuse
(See also “Resources” at the end of this course.)
Source: DAIP, 1984.
Anthony and Deborah met in their early twenties. Anthony’s source of income was an inheritance, and Deborah was completing a nursing program. After Deborah graduated, they married and Deborah began working at a local hospital. She was unhappy that she had to go to work and Anthony did not. When Deborah complained about the situation, Anthony spat on her and told her that his inheritance was only for him and that she needed to earn enough money to pay for her own support.
Deborah became pregnant and worked the night shift after the baby was born. Following the birth of a second child two years later, Deborah asked Anthony to get a job. He declined, arguing that he was taking care of the children and she could make more money than he could. Anthony did not allow Deborah access to either the checkbook or a credit card.
One morning, Deborah’s car was towed away because the car payments were in arrears. Anthony told her she would have to take the bus. When she again asked Anthony to get a job, he became angry, yelling and shoving and even throwing a chair at her during the argument. When Deborah told Anthony that she wanted a divorce, he threatened to take the children away forever. Deborah was ashamed to ask her friends or family for help and remained in the marriage for several more years until Anthony began to physically abuse the children.
Why Victims Stay
There are many reasons why victims stay in abusive relationships, and in any given relationship there may be numerous factors that form an interrelated web. These reasons fall into three broad categories: situational factors, emotional factors, and personal beliefs. It is important for healthcare professionals to understand the many reasons why victims remain in these relationships in order to provide appropriate treatment, assistance, and referrals.
- Economic dependence and inability to support herself and her children
- Fear of greater physical danger to herself and her children if they try to leave
- Fear of being hunted down and suffering a worse beating than before
- Fear of being killed if she leaves, often based on real threats by her partner
- Fear of emotional damage to the children
- Fear of losing custody of the children, often based on her partner’s remarks
- Lack of alternative housing; nowhere else to go
- Lack of job skills or the inability to get a job
- Social isolation resulting in lack of support from family and friends
- Social isolation resulting in lack of information about her alternatives
- Lack of understanding from family, friends, police, ministers, etc.
- Negative responses from community, police, courts, social workers, etc.
- Fear of involvement in the court process, sometimes due to bad prior experiences
- Fear of the unknown (“Better the devil you know than the devil you don’t”)
- Fear and ambivalence over making formidable life changes
- “Acceptable violence,” in which the violence escalates slowly over time and numbs the victim so that she is unable to recognize a pattern of abuse
- Fear of losing ties to the community, including the children leaving their school, leaving behind friends and neighbors, losing contact with her “old life”
- Ties to her home and belongings
- Family pressure (“Mom always told you it wouldn’t work out,” or “You made your bed, now sleep in it”)
- Fear of her abuser doing something to “get” her (reporting her to welfare, calling her workplace, etc.)
- Inability to access resources due to language barriers, disability, homophobia, etc.
- Lack of time needed to plan and prepare to leave
- Insecurity about being alone or on her own; fear she can’t cope with home and children by herself
- Loyalty (“He’s sick; if he had a broken leg or cancer, I would stay. This is no different.”)
- Pity, feeling sorry for him
- Wanting to help (“If I stay, I can help him get better.”)
- Fear that he will commit suicide if she leaves, often based on her partner’s remarks
- Denial (“It’s really not that bad. Other people have it worse.”)
- Love, particularly when the abuser is quite loving and lovable when he is not being abusive
- Love, especially when remembering what he used to be like
- Guilt, believing that their problems are all her fault, often with the agreement of her partner
- Shame and humiliation in front of the community (“I don’t want anyone else to know.”)
- Unfounded optimism that the abuser will change
- Unfounded optimism that things will get better, despite all evidence to the contrary
- Learned helplessness, as a result of trying every possible method to change things without success, thereby coming to expect failure (also seen with prisoners of war, hostages, those in extreme poverty, etc.)
- False hope (“He’s starting to do things I’ve been asking for,” such as counseling, anger management, etc.)
- Feeling responsible, as though she only needs to meet some set of vague expectations in order to earn the abuser’s approval
- Insecurity over her potential independence and lack of emotional support
- Guilt about the failure of the marriage/relationship
- Demolished self-esteem (“Just like he says, I’m too fat, stupid, ugly, etc., to leave.”)
- Simple exhaustion, feeling too tired and worn out from the abuse to leave
- Parenting: that the children need two parents (“A crazy father is better than none at all.”)
- Religious and family: pressure to keep the family together no matter what
- Duty (“I swore to stay married till death do us part.”)
- Responsibility: it is up to her to work things out and save the relationship
- Belief in the dream of growing up and living happily ever after
- Identity: being raised to feel that all women need a partner—even an abusive one—in order to be complete or accepted by society
- Violence: thinking all partners relate this way (often among women who experienced a violent childhood)
- Other religious and cultural beliefs
WHY ABUSED MEN STAY
While most victims of domestic violence are women, men are sometimes victims. Like women, men remain in these relationships for a variety of reasons. The most frequent seem to be:
- Protecting their children: afraid to leave their children alone with the abuser, that they will never be allowed to see their children again, that the abuser will turn the children against them
- Assuming blame (guilt-prone): believe that they deserve the abusive treatment or that it is their fault; feel responsible or that they can and should do something to fix things
- Dependency (or fear of independence): feel mental, emotional, or financial dependence on the abuser
Oregon Counseling, 2013.
ASSESSMENT, DOCUMENTATION, AND TREATMENT
Assessing for Signs and Symptoms
Every healthcare facility that serves women, children, and older adults needs to screen for potential domestic violence. This screening need not be lengthy. The screening can be part of the intake interview or included as part of the written history. Patients should have the opportunity to respond to the questions in a confidential setting outside the presence of the patient’s family, caregiver, or the person who brings the patient to the appointment.
Healthcare professionals should be alert for signs and symptoms that may be related to domestic violence:
- Delay in seeking care or missed appointments
- Vague or inconsistent explanations of injuries or nonspecific somatic complaints
- Depression, chronic pain, and social isolation
- Substance abuse and use of alcohol or drugs
- Signs of abuse in pregnant clients (because abuse often escalates during pregnancy)
- Lack of eye contact and/or an intimate partner who is reluctant to leave the woman alone with the healthcare professional
- Patient who is fearful, anxious, withdrawn, angry, nonresponsive, or afraid to talk openly
- Suicide attempts
DANGER ASSESSMENT INSTRUMENT
The Danger Assessment Instrument is an excellent tool and has been used for over 25 years by health professionals, law enforcement, and advocates. The tool consists of 20 questions that the client may respond to with yes/no answers. The various questions are weighted for risk factors associated with intimate partner homicide. Some of the risk factors include past death threats, partner’s employment status, and partner’s access to a gun. Culturally competent versions are now available to evaluate same-sex and immigrant relationships for lethality. The tool is available online for certified professionals to download after they have completed a brief online training and posttest.
(See “Resources” at the end of this course.)
Sources: Messing et al., 2013; Campbell et al., 2009.
During the physical examination, the clinician should:
- Look for injuries on many areas of the body, especially the face, throat, neck, chest, abdomen, and genitals.
- Note any bruises, burns, or wound patterns that resemble teeth marks, hand prints, belts, or cigarette tips.
- Note any pain or tenderness 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 adults.
- Be aware that the patient may wear a glove or sock to conceal a scalded hand or foot.
Following an established procedure for examination will ensure that no critical information is overlooked:
- Have the patient change into an exam gown that will allow all areas of the body to be examined.
- Check for injuries.
- Document physical findings in detail and include measurements, preferably using a report form specified for domestic violence exams.
- Photograph injuries, including long-distance, mid-range, and close-up perspectives. Photograph each injury with and without a scale.
- Conduct a mental status exam.
- Use open, nonjudgmental questions regarding the mechanism of injury.
- Do not cut clothing or discard any potential evidence. Collect, preserve, and maintain chain of custody. All evidence should be stored in paper bags. Wet evidence should be placed inside of a waterproof container and given to law enforcement for immediate processing.
It is important to remember that many victims of domestic violence may show no physical signs of injury at all. Nonfatal strangulation, which can be a strong predictor of future homicide, may leave no marks. Sexual assault may result in no visible trauma. In fact, there may be no physical signs resulting from the top five predictors of lethality: threatening to use a weapon, threatening to kill the victim, constant jealousy, strangulation, and forced sex.
The most dangerous domestic violence offenders strangle their victims. The most violent rapists strangle their victims. We used to think all abusers were equal. They are not. Our research has now made clear that when a man puts his hands around a woman, he has just raised his hand and said, “I’m a killer.” They are more likely to kill police officers, to kill children, and to later kill their partners. So, when you hear, “He choked me,” now we know you are on the edge of homicide.
Strangulation is one of the most lethal forms of domestic violence: unconsciousness may occur within 10 seconds and death within 4 minutes. Strangulation is also one of the best predictors for future homicide of victims of domestic violence. One study showed that “the odds of becoming an attempted homicide increased by about seven-fold for women who had been strangled by their partner” and that the risk of completed homicide increases to 800% (Glass et al., 2008).
Yet strangulation has been overlooked in the medical literature, and some states still do not adequately address this violence in their criminal statutes. As of January 1, 2017, 41 states have passed legislation that categorizes strangulation as a felony crime. Kentucky has attempted to pass such a law, but strangulation remains a misdemeanor offense in the state.
Many victims of strangulation do not seek medical attention because “they look fine.” When law enforcement officers respond to emergency calls, they may think the same, because in the majority of cases there are no visible signs.
While victims of strangulation may have no visible injuries, the lack of oxygen during the assault can cause serious trauma to the brain and lead to death days, or even weeks, later. Strangulation can have a devastating psychological effect on victims in addition to a potentially fatal outcome, including suicide.
In some cases, injuries may be apparent. A strangulation victim may struggle violently, which could lead to neck injuries. Efforts to fight back may also lead to injury on the face or hands of the assailant. Victims of strangulation may also experience difficulty breathing, speaking, or swallowing; nausea; vomiting; light headedness; headache; and involuntary urination and/or defecation (TISP, 2014).
(See also “Resources” at the end of this course.)
ASSESSING FOR OTHER CONDITIONS
Women who show signs of physical abuse should also be screened for sexually transmitted infections (STIs), including chlamydia, human papilloma virus, gonorrhea, trichomoniasis, bacterial vaginitis, and syphilis. One study found that women who are in an abusive relationship are more likely to acquire STIs and have a higher prevalence of STI risk behaviors such as not using condoms. The study suggests that clinicians should consider screening women who are in violent relationships for STIs (Hess et al., 2012).
Clients suffering from abuse may have complaints or injuries that include arthritis, irritable bowel syndrome, stomach ulcers, chronic pain, migraines, and eating disorders. Other closely associated complaints include insomnia, depression, posttraumatic stress disorder, panic disorder, and substance abuse.
SCREENING AMONG ELDERS
It is estimated that 10% of older persons experience abuse or neglect by their caregivers, but the majority of cases are never reported to authorities. Although it is unclear if screening for elder abuse mitigates the incidence, clinicians are encouraged to use validated screening tools such as the Elder Abuse Suspicion Index (EASI). If the clinician has concerns about the cognitive status of the patient, a two-step screening process may be used to evaluate the patient for dementia prior to screening for abuse.
Source: Hoover & Polson, 2014.
LACK OF SCREENING
Even though many healthcare professionals are alert to signs of potential child abuse, too few screen for domestic violence among adults. A meta-analysis by Sprague and colleagues (2012) revealed that the three most common clinician barriers to screening for domestic violence include time constraints (82%), knowledge deficit (68%), and lack of resources and/or support staff (63%). One half of the providers articulated that they felt that such screening was an invasion of the clients’ privacy or that the questions might be perceived as offensive, and nearly 50% expressed the opinion that they did not believe such screening was part of their role as clinicians or that it was a priority over other urgent issues.
Documenting Suspected Domestic Violence
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 to obtain a restraining order or to qualify for public housing, welfare, health and life insurance, and immigration relief.
Recommendations for documentation of suspected domestic violence include:
- With the patient’s permission, photograph the injuries whenever possible.
- Using a body map, document the location, number, type, and characteristics of injuries.
- Record the patient’s own words about how the injuries occurred, using quotation marks or prefaced by “the patient states” or “the patient reports” to indicate information that came directly from the patient rather than a third party; do not paraphrase.
- Describe the patient’s demeanor (crying, angry, agitated, upset) as well as the patient’s appearance.
- Identify the person whom the patient reports as the abuser using the patient’s own words, such as “my boyfriend kicked me.”
- Include the time of day when the patient is examined and, if possible, how much time has elapsed since the injuries occurred, using the patient’s own words (for example, “The patient states, ‘My husband punched me last night.’”).
- Use legible handwriting (if not documenting in an electronic record). Poor handwriting on medical records can cause documentation to be deemed inadmissible as evidence.
- Do not include personal opinion or conclusions in the documentation. Biased remarks can be inadmissable in court. Instead, document facts objectively so that others may draw their own conclusions.
- Do not use the terms domestic violence, DV, or intimate partner violence in the documentation. These are legal terms and are for the court to decide.
- Do not use terms that have specific legal meanings such as “patient alleges.”
- Document any reporting process that was followed per local or state protocol.
A documentation form for mandated reporters, although not required, is helpful to prompt the clinician to include all of the necessary information. The Kentucky Cabinet for Health and Human Services provides a form that can be downloaded from their website (see “Resources” at the end of this course).
When assessment and examination are complete, the clinician reviews any therapeutic protocols with the patient and provides a supportive and encouraging environment in which the patient can seek help and get support. This includes:
- Providing appropriate diagnostic and therapeutic interventions in collaboration with other professionals
- Providing verbal and written information about domestic violence and legal options
- Providing a listing of relevant community resources
- Making any necessary referrals
- Initiating mandatory reporting procedures when required
- Discharging the patient to a safe environment
It is also critical to understand and implement the facility’s established safety protocols.
REPORTING REQUIREMENTS IN KENTUCKY
Mandatory reporting of spouse abuse, child abuse, and abuse of those adults unable to protect themselves, such as the elderly or persons with a disability, is required by all persons in Kentucky and is not limited to healthcare professionals. Any person having reasonable cause to believe that a person of any age has been abused or neglected must report it to the Cabinet for Health and Family Services (CHFS). The Cabinet, in turn, is required to notify the appropriate law enforcement agency.
Kentucky statute specifically requires all healthcare professionals to provide an oral or written report to the CHFS when they suspect abuse, neglect, or exploitation. Certainty is not required to make a confidential report, nor is the consent of the patient.
After receiving a report of domestic violence, neglect, or abuse, the Cabinet will notify law enforcement, and an investigation, arrest, and prosecution of the abuser may follow. It is important that victims be made aware of this, because they may have no control over what will occur within the various systems.
How to Report
Any life-threatening situation should be reported to the police immediately by calling 911.
Reports of suspected abuse or neglect may be made by calling the Child/Adult Abuse Hotline of the Cabinet for Health and Family Services, local law enforcement or Kentucky State Police, or the County or Commonwealth Attorneys’ Office. The report can be made by telephone or in writing.
Furthermore, there are four ways to report domestic violence to the Cabinet for Health and Family Services:
- By phone to the Child/Adult Abuse Hotline (877-KYSAFE1 or 877-597-2331)
- By fax to 502-595-0895
- By email to email@example.com
- Online at https://prd.chfs.ky.gov/ReportAbuse/home.aspx on Monday-Friday from 8:00 a.m. to 4:30 p.m. Eastern Time
The state of Kentucky does not require that the report be made on a specific form, but a domestic violence/sexual assault documentation form is available online (see “Resources” at the end of this course).
Donna, an office nurse in a busy OB/GYN practice in Kentucky, noted multiple bruises in various stages of healing on her patient Brandy’s legs during a routine prenatal visit. Donna asked Brandy about the bruises, and Brandy stated they were the result of her husband kicking her. Brandy did not want to report the incident to the police, but Donna told her that she is required by law to notify the Cabinet for Health and Family Services. Donna gave Brandy a resource pamphlet on domestic violence and made a telephone report to the Cabinet immediately after Brandy’s appointment.
In the case of spousal abuse, KRS 209A.030 mandates that:
Any person, including, but not limited to, physician, law enforcement officer, nurse, social worker, dentist, cabinet personnel, coroner, medical examiner, alternate care facility employee, financial agent, or caretaker, having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter. Death of the adult does not relieve one of the responsibilities for reporting the circumstances surrounding the death.
An oral or written report shall be made immediately to the Cabinet upon knowledge of the occurrence of suspected abuse, neglect, or exploitation of an adult. Any person making such a report shall provide the following information, if known:
- Name and address of the adult, or of any other person responsible for his care
- Age of the adult
- Nature and extent of the abuse, neglect, or exploitation
- Evidence of previous abuse, neglect, or exploitation
- Identity of the perpetrator
- Identity of the complainant
- Any other information that the person believes might be helpful in establishing the cause of abuse, neglect, or exploitation
Upon receipt of the report, the Cabinet shall take the following action as soon as practical:
- Notify the appropriate law enforcement agency;
- Initiate an investigation of the complaint; and
- Make a written report of the initial findings together with a recommendation for further action, if indicated.
In addition to following mandatory reporting requirement laws, Kentucky nurses and other healthcare professionals should keep themselves informed of the current status of related statutes. Establishing good communication with local law enforcement and judicial offices in order to stay abreast of any changes is also recommended.
SPOUSAL ABUSE AND DEMENTIA
Healthcare workers may report spousal abuse to Adult Protective Services when a patient with dementia exhibits violent behavior, but if the violence is dementia-related and the client is receiving dementia care services, there may be nothing more that the APS worker can do. It may be prudent to attempt to have guns and other obvious weapons removed from the home or to notify the police.
There is a need for dementia care programs to develop policies for situations that involve clients who have histories of domestic violence. These policies should address how to assess future risk and what to do to ensure caregivers’ safety. Working with law enforcement to safeguard that violent elders with dementias are treated humanely is also important. Elder abuse is now being incorporated into domestic violence policies, and police are being instructed to use applicable domestic violence laws when responding to elder abuse cases.
Involving the police may result in more elders with dementias becoming incarcerated. Some people in the dementia care field are concerned that inappropriate actions (such as incarceration of a confused elder) may result from the interactions between law enforcement and Adult Protective Services. Cognitive decline is usually gradual, making it difficult to determine at which point people are no longer culpable for their actions. A response that is both fair and humane will require cooperation between law enforcement and adult protective services.
Source: Nerenberg, 2006.
On July 19, 2012, 77-year-old Rosetta Rosa shot and killed her husband of 54 years because she said he was sexually abusing their granddaughter. The granddaughter was not present at the time of the shooting. For the next two days after killing him, Ms. Rosa continued to prepare meals for her husband. Ms. Rosa underwent a series of interviews with psychiatrists and was found to be incompetent to stand trial due to progressive and irreversible dementia. The murder charge was dismissed in August of 2013. While in court for the hearing, Ms. Rosa asked if her husband was present (Hefler, 2013).
CARING FOR VICTIMS OF ABUSE
Healthcare professionals can begin by believing any patient who indicates she or he is being abused. The patient has shown trust and courage to disclose the facts. Skillful, nonjudgmental interviewing can help build trust and establish a therapeutic relationship. Holtz and Furniss (1993) developed the following guidelines for care of an abused woman:
Assure the woman she is not alone. Isolation enforced by her abusive partner prevents her from understanding that others are in a similar situation and that healthcare professionals can help.
Express the belief that violence against the woman is unacceptable in any situation and that it is not her fault.
Ensure confidentiality. She may fear (justifiably) that the abuser will retaliate.
Document the case thoroughly.
Educate the woman about the cycle of violence, the likelihood of repeated violence, and her options for ending the abuse.
Safety. Help the woman formulate a plan of action for either leaving or remaining safely in the relationship. Provide information about available resources, such as hotline and shelter numbers. Suggest she pack a quick getaway bag with personal items to be hidden or left with a trusted neighbor or friend. Recommend she have an extra set of car keys, house keys, money, and any legal documents needed for identification.
Healthcare agencies should maintain lists of local resources, including shelters and legal assistance. Be aware of the need to ask a victim if coming across such information is likely to upset the abuser. If at all possible, have available a concealable resource list for victims who need it.
Helping the Children
When leaving the home because of abuse, abuse victims with children should take their children with them to prevent them from being abused or held hostage by the abuser. Children living with an abuser need help in protecting themselves. Depending on their age, children can:
- Learn about the cycle of violence and when violence is most likely to occur
- Recognize the clues that suggest the abuser is getting upset
- Watch for signs of drinking or drug abuse by the abuser
- Avoid behaviors that may worsen the abuser’s stress
- Avoid areas of the house where violence usually occurs
- Leave the house when domestic violence starts
- Stay with a friend or relative
For example, a mother can have her children go to bed with their shoes on so they can escape at a moment’s notice if their alcoholic father becomes violent. She can train them to run to a trusted neighbor’s house and ask the neighbor to call the police.
A safety plan is something that an abuse victim can begin working on at any time. In a safety plan, the individual develops personalized and practical steps, both physical and psychological, to take while in the relationship, when planning to leave, and after leaving. Details on the elements of a safety plan, along with forms that a victim can use to create a plan, are available online. Nurses and other healthcare professionals should keep such forms and/or information available with other resources for domestic abuse victims.
Healthcare professionals can also use the following questions to evaluate immediate safety issues:
- Where is the abuser now?
- Does the abuser know where the client is now?
- Has the abuser threatened to use weapons?
- Are weapons available to the abuser?
- Is the abuser intoxicated?
- Does the abuser have a criminal record?
- Are there children? Are they safe now?
- Are they being abused?
- Is the abuser verbally threatening the client?
- Is the abuser frightening relatives and friends?
(See “Resources” at the end of this course.)
Obtaining a Protective Order
A protective order is a document that is signed by a judge and directs a specific person to stay away from the person who is seeking the protection. Other restrictions covered by protective orders can include travel and gun ownership. In addition to protecting current and former abused spouses and intimate partners, children and victims of stalking may benefit from protective orders.
According to KRS 209.01, et seq. (Kentucky Adult Protective Act) and KRS 403.715, et seq. (Domestic Violence and Abuse), a protective order can be issued to both male and female victims of domestic violence who are family members, in a current intimate partnership, formerly were in an intimate partner relationship, or who are stalking victims.
There are two types of civil protective orders:
- Emergency protective order (EPO): an immediate temporary order for up to 14 days and that can be renewed once
- Domestic violence order (DVO): a long-term order for up to 3 years and that can be renewed as many times as needed
When a protective order is issued, a copy of the order is given to the appropriate law enforcement agency within 24 hours, and a copy is also entered in the domestic violation records of the Law Information Network of Kentucky (Thomson Reuters, 2016).
CIVIL VERSUS CRIMINAL LAW
In Kentucky, protective orders are issued under the civil law system. When a victim asks the court for protection from the abuser, the victim is not asking the court to arrest that person for committing a crime. But if the abuser violates the civil court order of protection, he may then face legal consequences, including incarceration. In a civil case, the victim has the right to drop the charges or remove the protective order.
The criminal law system handles all cases that involve crimes such as assault, harassment, theft, etc. A criminal complaint involves the abuser being charged with a crime. In a criminal case, the district attorney is the one who can decide to drop the case and the victim does not have any control over whether or not the case continues (WomensLaw.org, 2008).
A MODEL PROTOCOL FOR ADDRESSING DOMESTIC VIOLENCE
It is critical in any clinical setting to develop protocols that assist and support staff when caring for victims of domestic violence. A protocol enables the staff to respond to domestic violence in a comprehensive and consistent manner. Any protocol should include screening, identification/assessment, treatment, documentation, safety planning, discharge planning, and referral. A protocol can be comprehensive or brief, but it should adequately provide the staff with a blueprint for preparing for and responding effectively and efficiently to patients experiencing domestic violence.
The minimal elements that should be included are:
- Definitions: Include types of abuse and the persons who are covered by the protocol. Elder abuse and child abuse may be addressed separately.
- Principles: Include the institution’s philosophy about and commitment to addressing domestic violence.
- Identification and assessment procedures: Specify who is to do the assessment, screening tools and procedures, and how to ensure safety and confidentiality.
- Intervention procedures: Include interviewing strategies, safety assessment and planning, and discharge instructions. Addendums should address educational materials.
- State reporting requirements: Clarify the law. Include reporting procedures and forms as required. Define who is responsible for making the report.
- Confidentiality: Clarify privacy laws and ensure that the disclosure of health information serves to improve the health and safety of the victim.
- Collection of evidence and photographs: Include procedures for collection, storage, and release of evidence. Include procedures for taking photos and utilizing release forms.
- Medical record documentation: Clarify what information is to be included in the medical record.
- Referral and follow-up: Include instructions for resources, how to make referrals, domestic violence programs, and other community agencies. Update phone numbers regularly. Include instructions for victims to have at least one follow-up appointment.
- Staff education plan: Describe ongoing training for all staff.
Source: Futures Without Violence, 2016.
COMMUNITY RESOURCES AND PREVENTION
Domestic Violence Services in Kentucky
The YWCA in Louisville opened Kentucky’s first spouse abuse shelter in 1977. Shortly thereafter, in 1981, the Kentucky Domestic Violence Association (KDVA) was founded as a statewide coalition whose members included all domestic violence programs in the state. The purpose of the coalition is to provide mutual support, information, resource sharing, and technical assistance; to coordinate services; and to collectively advocate for battered women and their children on statewide issues. The agency has since been replaced by the Kentucky Coalition Against Domestic Violence (KCADV).
Working together with the Department for Social Services, KDVA helped establish the Individual Development Accounts program in which matched savings help survivors purchase a home or a car. Grants for this program are planned through September 2019 (U.S. DHHS, 2016). Private and state-funded spouse abuse centers shelter both adults and victims throughout the state of Kentucky. There is a state-funded spouse abuse center in each of the 15 Area Development Districts that provides shelter, counseling, advocacy, support groups, and children programs (KY CHFS, 2013). These programs continue under the direction of KCADV.
Spouse abuse centers provide a variety of related support services to residents and nonresidents that include:
- Crisis line services
- Legal/court advocacy
- Follow-up counseling
- Information and referral
- Community education programs
- Professional training
- Case management
- Safety planning
- Support groups
- Housing assistance
- Job search, resumé writing, improving basic job skills
- Children’s groups
- Parenting education
- Drug and alcohol issues
KCADV is also a leader in efforts to prevent future domestic violence through public awareness and community education efforts such as an annual conference with the Kentucky Association of Sexual Assault programs. It works together with schools, local professionals, and community groups to increase understanding of domestic violence issues. KCADV and its members have also worked to help pass legislation related to domestic violence, such as laws addressing warrantless arrest, emergency protective orders, and marital rape, to name a few (KCADV, 2017).
The Kentucky Claims Commission provides victims with crime compensation funds, assisting victims of violent crime who have no other resources to pay for the medical, funeral, counseling, dental, or other expenses resulting from the crime. Assistance also provides for lost wages of the victim or loss of support for someone dependent on the victim (Ky.gov, 2016).
Prevention of domestic violence and early identification and treatment of victims eliminates much pain and suffering for survivors and benefits all healthcare systems in the long run.
Prevention is something everyone can participate in. Empowerment should be the guiding force behind victim advocacy and is something all healthcare professionals can promote. Remember to always:
- Respect confidentiality
- Believe and validate experiences
- Acknowledge injustice
- Respect autonomy
- Help plan for future safety
Communities also benefit from advocacy activities. Healthcare professionals may be able to do one or more of the following:
- Provide professional or community education about family violence
- Participate actively to develop and maintain community resources for prevention of domestic violence
- Participate actively to develop and maintain community resources for intervention in domestic violence situations
- Participate on a Domestic Violence Coordinating Council
Domestic violence in any form deprives those who are affected of their basic human rights. Children, who are the future of our society, are witnesses of this abuse and suffer irreparable damage from the exposure. Healthcare professionals can make a critical difference in ending this costly, destructive epidemic and interrupt the transmission of violence from generation to generation. By being alert to the possibility of domestic abuse in patients of every age, race, cultural, and socioeconomic group, nurses can identify, protect, and assist victims in resolving their situations.
To accomplish this goal, healthcare professionals must be present for their patients, learn to ask the right questions, and speak for those who are too afraid to ask for help. Nurses must put forth a coordinated effort with advocacy groups, community resources, and law enforcement in order to be effective change agents.
National Domestic Violence Hotline
Rape, Abuse, and Incest National Network
Violence prevention (CDC)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course.
Ard KL & Makadon HJ. (2011). Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. Journal of General Internal Medicine, 26(8), 930–3. Retrieved from http://doi.org/10.1007/s11606-011-1697-6
Associated Press-MTV. (2009). A thin line: 2009 AP-MTV digital abuse study. Retrieved from http://www.research.ATHINLINE.org
Auchter B. (2010). Men who murder their families: what the research tells us. National Institute of Justice Journal, 266, 10–2. Retrieved from https://www.nij.gov
Black M, Basile K, Breiding M, Smith S, Walters M, Merrick M, Chen J, & Stevens, M. (2011). The national intimate partner and sexual violence survey (NISVS) summary report 2010. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov
Breiding M, Basile K, Smith S, Black M, & Mahendra R. (2015). Intimate partner violence surveillance: uniform definitions and recommended data elements. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov
Breiding M, Smith S, Basile K, Walters M, Chen J, and Merrick M. (2011). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization: national intimate partner and sexual violence survey, United States. Morbidity and Mortality Weekly Report, 63(SS-8), 1–18. Retrieved from https://www.cdc.gov
California Clinical Forensic Medical Training Center (CCFMTC). (2014). Forensic photography: documentation of the physical effects of violence. Participant manual. Sacramento: Author.
Campbell JC, et al. (2003). Risk factors for femicide in abusive relationships: results from a multisite case control study. American Journal of Public Health, 93(7), 1089–92. Retrieved from https://www.ncbi.nlm.nih.gov
Campbell JC, Webster D, & Glass N. (2009). The danger assessment: validation of a lethality risk assessment instrument for intimate partner femicide. Journal of Interpersonal Violence, 24(4), 653–74. doi:10.1177/0886260508317180
Capaldi DM, Knoble NB, Shortt JW, & Kim HK. (2012). A systematic review of risk factors for intimate partner violence. Partner Abuse, 3(2), 231–80. doi:10.1891/1946-6522.214.171.124
Centers for Disease Control and Prevention (CDC), Injury Prevention and Control, Division of Violence Prevention. (2016a). Intimate partner violence: definitions. Retrieved from https://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2016b). Teen dating violence. Retrieved from https://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2016c). Intimate partner violence: risks and protective factors. Retrieved from https://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2015). Intimate partner violence: consequences. Retrieved from https://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2012). Intimate partner violence. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2009). Adverse Childhood Experience (ACE) study. Retrieved from http://www.cdc.gov
Child Welfare Information Gateway. (2015). Understanding the effects of maltreatment on brain development. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from https://www.childwelfare.gov
Cho H. (2012). Use of mental health services among Asian and Latino victims of intimate partner violence. Violence Against Women, 18(4), 404–19. Retrieved from http://vaw.sagepub.com
CNN. (2015). Beaten and scalped: one woman’s horrific story of violence. Retrieved from http://wjbf.com
Dillon G, Hussain R, Loxton D, & Rahman S. (2013). Mental and physical health and intimate partner violence against women: a review of the literature. International Journal of Family Medicine, 2013, article ID 313909, 15 pages. doi:10.1155/2013/313909
Domestic Abuse Intervention Project (DAIP). (1984). Power and control wheel. Retrieved from http://www.theduluthmodel.org
Futures Without Violence. (2016). Domestic violence and healthcare protocols. Retrieved from https://secure3.convio.net
Glass N, Laughon K, & Taliaferro E. (2008). Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Medicine, 35(3), 329–35. doi:10.1016/j.jemermed.2007.02.065
Gwinn C. (2017). What we learned in 2016: update from the training institute on strangulation prevention webinar. [PowerPoint slides]. Retrieved from http://www.strangulationstraininginstitute.com
Hefler J. (2013).Woman with Alzheimer’s won’t be tried in husband’s killing. The Inquirer (August 21). Retrieved from http://articles.philly.com
Hess K, Javanbakht M, Brown J, Weiss R, Hsu P, & Gorbach P. (2012). Intimate partner violence and sexually transmitted infections among young adult women. Sexually Transmitted Diseases, 39(5). doi:10.1097/OLQ.0b013e3182478fa5
Holtz H & Furniss KK. (1993). The health care provider’s role in domestic violence. Trends in Healthcare Law and Ethics, 15, 519–22.
Hoover R & Polson M. (2014). Detecting elder abuse and neglect: assessment and prevention. American Family Physician, 89(6), 453–60.
Ingram B. (2017). Secrecy and silence: response to intimate partner violence in the black community. Peace over Violence. Retrieved from http://www.peaceoverviolence.org
Kann L, Kinchen S, Shanklin S, Flint K, Hawkins J, Harris W, et al. (2014). Youth risk behavior surveillance—United States, 2013. MMWR, 63(SS04), 1–168. Retrieved from https://www.cdc.gov
Kendall-Tacket KA. (2007). Violence against women and the perinatal period: the impact of lifetime violence and abuse on pregnancy, postpartum and breastfeeding. Trauma, Violence and Abuse, 8(3), 34–5. doi:10.1177/1524838007304406
Kentucky Cabinet for Health and Family Services (KY CHFS). (2013). Abuse, neglect, and violence. Administrative reference. Volume 1. July 1. Retrieved from http://chfs.ky.gov
Kentucky Coalition Against Domestic Violence (KCADV). (2017). About us. Retrieved from https://kcadv.org
Kentucky Coalition Against Domestic Violence (KCADV). (2016). Economic empowerment program. Retrieved from https://www.kcadv.org
Kentucky Court of Justice. (2016). House bill 8: domestic/dating violence protections. Retrieved from http://courts.ky.gov
Kentucky Legislature. (2016). Kentucky Revised Statutes. Definitions for KRS 403.715 to 403.785. Retrieved from http://www.lrc.ky.gov
Kentucky State Police (KSP). (2015). 2015 Crime in Kentucky. Retrieved from http://www.kentuckystatepolice.org
Ky.gov. (2016). Kentucky claims commission (formerly the crime victims compensation program). Retrieved from http://cvcb.ky.gov
Lannert B, Garcia A, Smagur K, Yalch M, Lendosky A, Bogat G, et al. (2014). Relational trauma in the context of intimate partner violence. Child Abuse and Neglect, 38(12), 1966. doi:10.1016/j.chiabu.2014.10.002
Law Center to Prevent Gun Violence (2016). Domestic violence and firearms in Kentucky. Retrieved from: http://smartgunlaws.org
Lentz L. (2011). Ten tips for documenting domestic violence. Nursing Critical Care, 6(4), 48. Retrieved from http://journals.lww.com
McFarlane JM, Campbell JC, Wilt S, Sachs CJ, Ulrich Y, & Xu X. (1999). Stalking and intimate partner femicide. Homicide Studies, 3(4), 300–16.
Messing J, Amanor-Boadu Y, Cavanaugh C, Glass N, & Campbell J. (2013). Culturally competent intimate partner risk assessment: adapting the danger assessment for immigrant women. Social Work Research, 37(3), 263–75. doi:10.1093/swr/svt019
National Alliance to End Homelessness (NAEH). (2014). Domestic violence. Retrieved from http://www.endhomelessness.org
National Center on Elder Abuse (NCEA). (2016). Statistics/data. Retrieved from https://ncea.acl.gov
National Coalition of Antiviolence Programs (NCAVP). (2012). Special issues in LGBT domestic violence. Retrieved from http://www.ncavp.org
National Domestic Violence Hotline (NDVH). (2013). Pregnancy and abuse. Retrieved from http://www.thehotline.org
National Immigrant Justice Center (NIJC). (2013). Pro bono attorney manual on immigration relief for crime victims: U visas. Retrieved from http://immigrantjustice.org
National Resource Center for Victims of Crime (NRCVC). (2014). Stalking resource fact sheet. Retrieved from http://www.victimsofcrime.org
Nerenberg L. (2006). Perpetrators with dementia. Prevent Elder Abuse (August). Retrieved from http://preventelderabuse.blogspot.com
Nosek MA, Foley CC, Hughes RB, et al. (2001). Vulnerabilities for abuse among women with disabilities. Sexuality and Disability, 19, 177–90. doi: https://doi.org/10.1093/bjsw/bcq057
Oregon Counseling. (2013). About domestic violence against men. Retrieved from http://www.oregoncounseling.org
Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. (2011). Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstetrics and Gynecology, 118(5), 1056–63. doi:10.1097/AOG.0b013e31823294da
Powers R. (2016). Domestic violence in the U.S. military. The Balance, November 9. Retrieved from https://www.thebalance.com
Rape, Abuse, and Incest National Network (RAINN). (2016). Mandatory reporting requirements: the elderly Kentucky. Retrieved from https://apps.rainn.org
Riviello R. (2014). How to recognize and act on risk factors for domestic violence homicide. American College of Emergency Physicians Now. Retrieved from http://www.acepnow.com
Sabri B, Stockman JK, Campbell JC, O’Brien S, Campbell D, Callwood GB, et al. (2014). Factors associated with increased risk for lethal violence in intimate partner relationships among ethnically diverse black women. Violence and Victims, 29(5), 719–41. Retrieved from http://doi.org/10.1891/0886-6708.VV-D-13-00018
Sanctuary for Families. (2014). Domestic violence and LGBT community. Retrieved from http://www.sanctuaryforfamilies.org
Seff LR, Beaulaurier RL, & Newman FL. (2008). Nonphysical abuse: findings in domestic violence against older women study. Journal of Emotional Abuse, 8(3), 355–74. Retrieved from http://beau.fiu.edu
Silverman JG, Decker MR, Reed E, & Raj A. (2006). Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health. American Journal of Obstetrics and Gynecology, 195(1), 140–8. doi:10.1016/j.ajog.2005.12.052
Smith DL & Strauser DR. (2008). Examining the impact of physical and sexual abuse on the employment of women with disabilities in the United States: an exploratory analysis. Disability and Rehabilitation, 30(14), 1039–46. Retrieved from http://dx.doi.org/10.1080/09637480701539542
Sorenson S. (2006). Firearm use in intimate partner violence: a brief overview. Evaluation Review, 30(3), 229–36. doi:10.1177/0193841X06287220
Sprague S, Madden K, Simunovic N, Godin K, Pham N, Bhandari M, et al. (2012). Barriers to screening for intimate partner violence. Women and Health, 52(6). Retrieved from http://www-ncbi-nlm-nih-gov.ezproxyhhs.nihlibrary.nih.gov
Thomson Reuters. (2016). Kentucky protective orders laws. FindLaw. Retrieved from http://statelaws.findlaw.com
Training Institute on Strangulation Prevention (TISP). (2014). Strangulation documentation forms. Retrieved from http://www.strangulationtraininginstitute.com
U.S. Census Bureau. (2016). Quick facts. Retrieved from http://www.census.gov
U.S. Department of Homeland Security (U.S. DHS). (2016). U and T visa law enforcement resource guide. Retrieved from https://www.dhs.gov
U.S. Department of Homeland Security (U.S. DHS). (2014). U visa. Retrieved from http://www.uscis.gov
U.S. Department of Health and Human Services (U.S. DHHS). (2016). Assets for independence resource center. Retrieved from http://idaresources.acf.hhs.gov
U.S. Department of Justice. (2016). Stalking. Retrieved from https://www.justice.gov
U.S. Department of Justice, Office on Violence against Women. (2010). About domestic violence. Retrieved from http://www.ovs.usdoj.gov
Verizon Foundation. (2013). Verizon Foundation and MORE Magazine survey: exploring the relationship between domestic violence and chronic health conditions. Retrieved from https://www.verizon.com
Violence Policy Center. (2015). When men murder women. Retrieved from http://www.vpc.org
Walker LE. (2017). The battered woman syndrome (4th ed.). New York: Springer Publishing Company.
WomensLaw.org. (2008). Kentucky statutes. Retrieved from http://www.womenslaw.org
Women’s Rural Advocacy Programs (WRAP). (2007). Why women stay: the barriers to leaving. Retrieved from http://www.letswrap.com