Family and domestic violence (including child abuse, intimate partner abuse, and elder abuse) is a common problem in the United States. Family and domestic health violence are estimated to affect 10 million people in the United States every year. It is a national public health problem, and virtually all healthcare professionals will at some point evaluate or treat a patient who is a victim of some form of domestic or family violence.
Unfortunately, each form of family violence begets interrelated forms of violence, and the "cycle of abuse" is often continued from exposed children into their adult relationships, and finally to the care of the elderly.
Domestic and family violence include a range of abuse including economic, physical, sexual, emotional, and psychological toward children, adults, and elders.
Intimate partner violence includes stalking, sexual and physical violence, and psychological aggression by a current or former partner. In the United States, as many as one in four women and one in nine men are victims of domestic violence. Domestic violence is thought to be underreported. Domestic violence affects the victim, families, co-workers, and community. It causes diminished psychological and physical health, decreases the quality of life, and results in decreased productivity.
The national economic cost of domestic and family violence is estimated to be over 12 billion dollars per year. The numbers of individuals affected is expected to rise over the next 20 years with the increase in the elderly population.
Domestic and family violence is difficult to identify, and many cases go unreported to health professionals or legal authorities. Due to the prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physician assistants, nurse practitioners, and physicians will at some point evaluate and possibly treat a victim or perpetrator of domestic or family violence.
Family and domestic violence are abusive behaviors in which one individual gains power over another individual.
Center for Disease Control and Prevention (CDC)
Domestic violence, spousal abuse, battering, or intimate partner violence, is typically the victimization of an individual with whom the abuser has an intimate or romantic relationship. The CDC defines domestic violence as "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner."
Domestic and family violence has no boundaries. This violence occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether in the form of emotional, psychological, sexual, or physical violence, is common in our society and should develop the ability to recognize it and make the appropriate referral.
Violence Abuse Types
The types of violence include stalking, economic, emotional or psychological, sexual, neglect, Munchausen by proxy, and physical. Domestic and family violence occurs in all races, ages, and sexes. It knows no cultural, socioeconomic, education, religious, or geographic limitation. It may occur in individuals with different sexual orientations.
Reason Abusers Need to Control
Risk factors for domestic and family violence include individual, relationship, community, and societal issues. There is an inverse relationship between education and domestic violence. Lower education levels correlate with more likely domestic violence. Childhood abuse is commonly associated with becoming a perpetrator of domestic violence as an adult. Perpetrators of domestic violence commonly repeat acts of violence with new partners. Drug and alcohol abuse greatly increases the incidence of domestic violence.
Children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, the gender roles can be reversed.
Domination may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.
Domestic violence is a serious and challenging public health problem. Approximate 1 in 3 women and 1 in 10 men 18 years of age or older experience domestic violence. Annually, domestic violence is responsible for over 1500 deaths in the United States.
Domestic violence victims typically experience severe physical injuries requiring care at a hospital or clinic. The cost to individuals and society is significant. The national annual cost of medical and mental health care services related to acute domestic violence is estimated at over $8 billion. If the injury results in a long-term or chronic condition, the cost is considerably higher.
Financial hardship and unemployment are contributors to domestic violence. An economic downturn is associated with increased calls to the National Domestic Violence Hotline.
Fortunately, the national rate of nonfatal domestic violence is declining. This is thought to be due to a decline in the marriage rate, decreased domesticity, better access to domestic violence shelters, improvements in female economic status, and an increase in the average age of the population.
Age, family income, and ethnicity are all risk factors for both sexual abuse and physical abuse. Gender is a risk factor for sexual abuse but not for physical abuse.
Each year there are over 3 million referrals to child protective authorities. Despite often being the first to examine the victims, only about 10% of the referrals were from medical personnel. The fatality rate is approximately two deaths per 100,000 children. Women account for a little over half of the perpetrators.
Intimate Partner Violence
According to the CDC, 1 in 4 women and 1 in 7 men will experience physical violence by their intimate partner at some point during their lifetimes. About 1 in 3 women and nearly 1 in 6 men experience some form of sexual violence during their lifetimes. Intimate partner violence, sexual violence, and stalking are high, with intimate partner violence occurring in over 10 million people each year.
One in 6 women and 1 in 19 men have experienced stalking during their lifetimes. The majority are stalked by someone they know. An intimate partner stalks about 6 in 10 female victims and 4 in 10 male victims.
At least 5 million acts of domestic violence occur annually to women aged 18 years and older, with over 3 million involving men. While most events are minor, for example grabbing, shoving, pushing, slapping, and hitting, serious and sometimes fatal injuries do occur. Approximately 1.5 million intimate partner female rapes and physical assaults are perpetrated annually, and approximately 800,000 male assaults occur. About 1 in 5 women have experienced completed or attempted rape at some point in their lives. About 1% to 2% of men have experienced completed or attempted rape.
The incidence of intimate partner violence has declined by over 60%, from about ten victimizations per 1000 persons age 12 or older to approximately 4 per 1000.
Due to underreporting and difficulty sampling, obtaining accurate incidence information on elder abuse and neglect is difficult. Elderly abuse is thought to occur in 3% to 10% of the population of elders.
Elderly patients may not report due to fear, guilt, ignorance, or shame. Clinicians underreport elder abuse due to poor recognition of the problem, lack of understanding reporting methods and requirements, and concerns about physician-patient confidentiality.
There may be some pathologic findings in both the victims and perpetrators of domestic violence. Certain medical conditions and lifestyles make family and domestic violence more likely.
While the research is not definitive, a number of characteristics are thought to be present in perpetrators of domestic violence. Abusers tend to:
Domestic violence at home results in emotional damage which exerts continued effects as the victim matures.
Pregnant and Females
The American College of Obstetricians and Gynecologists (ACOG) recommends all women be assessed for signs and symptoms of domestic violence, during regular and prenatal visits. Providers should offer support and referral information.
The danger of domestic violence is particularly acute as both mother and fetus are at risk. Healthcare professionals should be aware of the psychological consequences of domestic abuse during pregnancy. There is more stress, depression, and addiction to alcohol in abused pregnant women. These conditions may harm the fetus.
Gay, Lesbian, Bisexual, and Transgender
Domestic violence occurs in gay, lesbian, bisexual, and transgender couples, and the rates are thought to be similar to a heterosexual woman, approximately 25%.
Gay, lesbian, bisexual, and transgender victims may be reticent to report domestic violence. Part of the challenge may be that support services such as shelters, support groups, and hotlines are not regularly available. This results in isolated and unsupported victims. Healthcare professionals should strive to be helpful when working with gay, lesbian, bisexual, and transgender patients.
Usually domestic violence is perpetrated by men against women; however, females may exhibit violent behavior against their male partners.
Although women are the most common victims of domestic violence, healthcare professionals should remember that men may also be victims and should be evaluated if there are indications present.
Elderly are often mistreated by their spouses, children, or relatives.
Elder domestic violence may be financial or physical. The elderly may be controlled financially. Elders are often hesitant to report this abuse if it is their only available caregiver. Victims are often dependent, infirm, isolated, or mentally impaired. Healthcare professionals should be aware of the high incidence of abuse in this population.
The history and physical exam should be tailored to the age of the victim.
The most common injuries are fractures, contusions, bruises, and internal bleeding. Unexpected injuries to pre-walking infants should be investigated. The caregiver should explain unusual injuries to the ears, neck, or torso; otherwise, these injuries should be investigated.
Children who are abused may be unkempt and/or malnourished. They may display inappropriate behavior such as aggression, or may be shy, withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. School attendance is usually poor.
Intimate Partner Abuse
Approximately one-third of women and one-fifth of men will be victims of abuse. The most common sites of injuries are the head, neck, and face. Clothes may cover injuries to the body, breasts, genitals, rectum, and buttocks. One should be suspicious if the history is not consistent with the injury. Defensive injuries may be present on the forearms and hands. The patient may have psychological signs and symptoms such as anxiety, depression, and fatigue.
Medical complaints may be specific or vague such as headaches, palpitations, chest pain, painful intercourse, or chronic pain.
Intimate Partner Abuse: Pregnancy and Female
Abuse during pregnancy may cause as much as 10% of pregnant hospital admissions. There are a number of historical and physical findings that may help the provider identify individuals at risk.
If the examiner encounters signs or symptoms, she should make every effort to examine the patient in private, explaining confidentiality to the patient. Be sure to ask caring, empathetic questions and listen politely without interruption to answers.
Intimate Partner Abuse: Same Sex
Same-sex partner abuse is common and may be difficult to identify. Over 35% of heterosexual woman, 40% of lesbians, 60% of bisexual woman experience domestic violence. For men, the incidence is slightly lower. In addition to common findings of abuse, perpetrators may try to control their partners by threatening to make their sexual preferences public.
The provider should be aware there are fewer resources available to help individuals that are victims; further, the perpetrator and victim may have the same friends or support groups.
Intimate Partner Abuse: Men
Men represent as much as 15% of all cases of domestic partner violence. Male victims are also less likely to seek medical care so the incidence may be underreported. These victims may have a history of child abuse.
Health professionals should ask geriatric patients about abuse, even if signs are absent.
Domestic violence may be difficult to uncover when the victim is frightened, especially when he or she presents to an emergency department or healthcare practitioner's office. The key is to establish an assessment protocol and maintain an awareness of the possibility that domestic and family violence may be the cause of the patient’s signs and symptoms. Screening should be carried out in primary care, obstetric and gynecologic, psychiatric, pediatric, urgent care, and emergency departments.
Establishing that injuries are related to domestic abuse is a challenging task. Life and limb-threatening injuries are the priority. After stabilization and physical evaluation, laboratory tests, x-rays, CT, or MRI may be indicated. It is important that healthcare professionals first attend to the underlying issue that brought the victim to the emergency department.
Assuming the patient is stable and not in pain, a detailed assessment of victims should occur after disclosure of abuse. Assessing safety is the priority. A list of standard prepared questions can help alleviate the uncertainty in the patient's evaluation. If there are signs of immediate danger, refer to advocate support, shelter, a hotline for victims, or legal authorities.
A detailed history and careful physical exam should be performed. If head trauma is suspected, consider an ophthalmology consultation to obtain indirect ophthalmoscopy.
Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings similar to child abuse, as a consequence, they must be ruled out.
If bruises or contusions are present, there is no need evaluate for a bleeding disorder if the injuries are consistent with an abuse history. Some tests can be falsely elevated so a child abuse-specialist pediatrician or hematologist should review or follow-up these tests.
Gastrointestinal and Chest Trauma
The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults such as cranial sutures and incomplete bone growth. A fracture can be misinterpreted. If there is a concern for abuse, consider consulting a radiologist.
Imaging: Skeletal Survey
A skeletal survey is indicated in children younger than 2 years with suspected physical abuse. The incidence of occult fractures is as high as 1 in 4 in physically abused children younger than 2 years. The clinician should consider screening all siblings younger than 2 years.
The skeletal survey should include 2 views of each extremity; anteroposterior and lateral skull; and lateral chest, spine, abdomen, pelvis, hands, and feet. A radiologist should review the films for classic metaphyseal lesions and healing fractures, most often involving the posterior ribs. A “babygram” that includes only 1 film of the entire body is not an adequate skeletal survey.
Skeletal fractures will remodel at different rates which are dependent on the age, location, and nutritional status of the patient.
If abuse or head trauma is suspected, a CT scan of the head should be performed on all children aged six months or younger or children younger than 24 months if intracranial trauma is suspected. Clinicians should have a low threshold to obtain a CT scan of the head when abuse is suspected, especially in an infant younger than 12 months.
CT of the abdomen and pelvis with intravenous contrast is indicated in children who are unconscious, have traumatic abdominal findings such as abrasions, bruises, tenderness, absent or decreased bowel sounds, abdominal pain, nausea, or vomiting, or have elevation of the AST, an ALT greater than 80 IU/L, or lipase greater than 100 IU/L.
Photographs should be taken before treatment of injuries.
Intimate Partner and Elder
Evaluate for evidence of dehydration, electrolyte abnormalities, infection, substance abuse, improper medication administration, and malnutrition.
Domestic and family violence commonly results in legal prosecution of the perpetrator. Preferably, a team specializing in domestic violence is called in to assist with evidence collection.
Each health facility should have a written procedure for how to package and label specimens and maintain a chain of custody. Law enforcement personnel will often assist with evidence collection, and provide specific kits.
It is important to avoid destroying evidence. Evidence includes tissue specimens, blood, urine, saliva, and vaginal and rectal specimens. Saliva from bites can be collected; the bite mark is swabbed with a water-moistened cotton-tipped swab.
Clothing stained with blood, saliva, semen, and vomit should be retained for forensic analysis.
The priority is the ABCs and appropriate treatment of the presenting complaints. However, once the patient is stabilized, emergency medical services personnel may identify problems associated with violence.
Emergency Department and Office Care
Interventions to consider include:
The medical record is often evidence used to convict an abuser. A poorly document chart may result in an abuser going free and assaulting again.
Charting should include detailed documentation of evaluation, treatment, and referrals.
If the patient does not want to go to a shelter, provide telephone numbers for domestic violence or crisis hotlines and support services for potential later use. Provide the patient with instructions but be mindful that written materials may pose a danger once the patient returns home.
The differential diagnosis varies with the injury type of injury and age.
Bruises and Contusions
Without proper social service and mental health intervention, all forms of abuse can be recurrent and escalating problems, and the prognosis for recovery is poor. Without treatment, domestic and family violence usually recurs and escalates in both frequency and severity.
In children, the potential for poor outcomes is particularly high as abuse inflicts lifelong effects. In addition to dealing with the sequelae of physical injury, the mental consequences may be catastrophic. Studies indicate a significant association between child sexual abuse and increased risk of psychiatric disorders in later life. The potential for the cycle of violence to continued from childhood is very high.
Children raised in families of sexual abuse may develop:
There are multiple known and suspected negative health outcomes of family and domestic violence. There are long-term consequences to broken bones, traumatic brain injuries, and internal injuries.
Patients may also develop multiple comorbidities such as:
Screening: Reporting Family and Domestic Violence
Over 80% of victims of domestic and family violence seek care in a hospital; others may seek care in health professional offices, including dentists, therapists, and other medical offices. Routine screening should be conducted by all healthcare practitioners including nurses, physicians, physician assistants, dentists, nurse practitioners, and pharmacists. Screening is a critical component protecting victims and minimizing negative health outcomes.
Health professional interventions reduce the incidence of morbidity and mortality associated with domestic violence.
It is important to be aware of federal and state statutes governing domestic and family abuse. Remember that reporting domestic and family violence to law enforcement does not obviate detailed documentation in the medical record.
Federal Child Abuse Prevention and Treatment Act (CAPTA)
Each state has specific child abuse statues. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure recent act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation.
Elder Justice Act
The Elder Justice Act provides strategies to decrease the likelihood of elder abuse, neglect, and exploitation. The Act utilizes three significant approaches:
Patient Safety and Abuse Act
The Violence Against Woman Act makes it a federal crime to cross state lines to stalk, harass, or physically injure a partner; or enter or leave the country violating a protective order. It is a violation to possess a firearm or ammunition while subject to a protective order or if convicted of a qualifying crime of domestic violence. The victim also has a right to:
The following agencies provide national assistance for victims of domestic and family violence: