Intimate partner violence (IPV) is an enormous health problem, with annual excess health care costs of billions of dollars annually in the U.S ( NCIPC, 2003 ). There is an increased relative risk of both overall and diagnosis-specific hospitalizations among abused women. Intimate partner violence has a significant impact on women's health and use of health care ( Kernic, 2000 ). Among female Medica enrollees within the Allina Health Care System alone, it is estimated that over $6 million excess dollars are spent annually to provide health care services to female victims of IPV ( Bohn, 2001 ).

Wisner, Gilmer, Saltzman and Zink ( 1999 ) found female victims of IPV to incur health care costs approximately 92% greater than a random sample of female patients. Contrary to the findings of other studies, use of emergency room services was not a driving factor in the higher cost.

A wide range of studies conducted in the past 20+ years have found that 89-100% of reported cases of physical IPV involve women abused by men. While it is known that abuse occurs in gay, lesbian, bisexual, and transgender relationships, and there are men who are abused by female partners, the vast majority of abuse victims who report IPV are women abused by men. Health care professionals should realize that IPV is perpetrated primarily by men whether against male or female partners and the vast majority of IPV victims are women ( Tjaden & Thoennes, 1998 ).

Some statistics documenting the incidence include:

Limited research has been conducted on the rate of LGBT domestic violence. Early research suggested that LGBT domestic violence was more prevalent than violence in heterosexual relationships. However, the National Violence Against Women Survey found that women living with female intimate partners experience less intimate partner violence than women living with male intimate partners and men living with male intimate partners experience more intimate partner violence than do men who live with female intimate partners ( Tjaden and Thoennes, 2000 ).

Greenwood, Reif, Huang, Pollack, Canchola, and Catania ( 2002 ) studied the prevalence of battering victimization among 2,881 men who have sex with men. They found that 39% of the men, who were from four major urban areas, reported experiencing at least one type of intimate partner battering during the previous five years. The strongest demographic correlate of overall violence was being 40 years of age or younger. The strongest demographic correlates for physical and psychological/symbolic violence were education and HIV serostatus. Race, ethnicity, income, sexual orientation, and city of residence were not correlated with violence.

a. Child abuse

Child abuse is a serious public health problem due to children's vulnerability and the potential adverse long-term health outcomes. In a survey of more than 15,000 adults conducted by Vincent Felitti, Robert Anda, Dale Nordenberg and colleagues, 10.8% of adult patients acknowledge child physical abuse, 22% said they experienced sexual abuse in childhood, 12.5% indicated childhood exposure to domestic violence, and approximately 33% reported being emotionally abused ( Groves, 2001 ).

Young children are at the greatest risk for physical abuse. Forty-one percent of children killed by parents or caretakers are under 1 year of age and only 10% of child fatalities are over 4 years of age. Younger children are not only more physically vulnerable and less able to seek help, but they are also more likely to be suspected as victims and diagnosed as abused when injured, resulting in increased reporting rates ( Gelles, 1997 ).

Girls aged 10 to 12 are the most likely victims of sexual abuse by adults. Adolescents are underreported as victims of physical and sexual abuse. Not only are they less likely to be diagnosed and receive help, but they also are often considered delinquent, troublemakers, and contributors to their victimization ( Gelles, 1997 ).

These cases represent the following distribution of maltreatment types* ( NCCAN, 2001 ):

some cases involved more than one type of abuse/neglect

It is important to remember that these are only the rates of substantiated (reported, investigated, and adjudicated by law) cases. Physical and sexual abuse are difficult to substantiate because children are not brought in for medical care until signs of the abuse have disappeared. Furthermore, in cases where physical markers are present, it is often difficult to prove who is responsible.

b. Teen dating violence

Recent studies have pointed to intimate partner violence as a significant health issue for adolescents. It is associated with increased risk of substance use, unhealthy weight control behaviors, sexual risk behaviors, pregnancy, and suicidality. Approximately 1 in 5 female high school students report being physically and/or sexually abused by a dating partner ( Molidor, Tolman, & Kober, 2000 ; National Center for Injury Prevention and Control, 2001 ; Silverman, Raj, Mucci, & Hathaway, 2001 ).

A study done by Ackard and Neumark-Steiner ( 2001 ) reports results from the 1998 Minnesota Student Survey on dating violence. They found that one in ten girls and one in 20 boys report being raped or physically abused on dates and approximately six percent of Minnesota boys and girls report some type of date-related violence by the ninth grade. Youth who have been victimized by dating partners are more likely than their non-victimized peers to report having experienced emotional problems including suicidal thoughts, poor emotional well-being, low self esteem, and eating disorders.

These three categorizations or terms are often used interchangeably, but generally speaking refer to different situations. Studies have found that a significant portion of elder abuse is spousal abuse continuing into older age ( Brandl & Raymond, 1996 ). Elders can also be victimized by adult children, or other caregivers ( Brandl & Raymond, 1997 ).

The National Center for Injury Prevention and Control ( 2003 ) reports the following breakdown of elder maltreatment substantiated by adult protection agencies.

It is important to understand the dynamics of abuse in relationships in the societal context of what are known as the "---isms:" racism, classism, homophobia and heterosexism, ageism, and ableism. The "---isms" are personal or institutional forms of discrimination committed by members of the dominant, often majority, culture against individuals or groups from whom they are different, based on characteristics over which neither has any control, such as skin color or physical ability.

There can be multiple intersections between the experience of family violence and the experience of the "---isms." Examples include

The barriers abuse victims face are confounded by experiences of racism for people of color, homophobia and heterosexism for lesbian, gay, bi-sexual and transgendered (LGBT) people, and so on. This is why ongoing development of cultural competency skills is so critical to effective nursing practice.

The role of health care professionals in the area of primary, secondary, and tertiary prevention of family violence has slowly evolved as societal awareness has increased. Laws mandating the reporting of child abuse emerged in the 1960's (see appendix A, History of Child Protection). The first battered women's shelters were founded in the 1970s. In the late 1980s and early 1990s most states enacted elder abuse laws ( Haywood & Scott, 1999 ). In Minnesota, health care professionals are mandated to report all cases of suspected abuse of vulnerable adults. With the genesis of the community responses to domestic violence, partnerships evolved between health care organizations and domestic abuse advocacy services.

While research clearly documents the major impact of family violence on health, many clinics, hospitals, and other health care sites across the country still resist universal screening. In fact, despite health care professionals in the US being in an optimal position to intervene, most states, including Minnesota, receive a failing grade in terms of training, screening, protocols, reporting, insurance, and legislation and public policy ( Family Violence Prevention Fund, 2001 ). There is much more that policy makers can and should do to improve the health care response. For example, something as simple as a best of practice standard has yet to be agreed upon. Nursing can and should take leadership in crafting those policies.

The occurrence of family violence is strongly influenced by cultural forces. Rates of family violence vary from country to country. It is difficult to make accurate country to country comparisons of the incidence of family violence because methods of data collection are not held constant. Generally speaking, cultures that value the care of children and elders, have strong social welfare policies, protect the rights of women, and have strong social sanctions against violent behavior have lower rates of family violence.

The United Nations Children's Fund ( UNICEF, 2000 ) reported that even with "spotty" statistics, one-fifth to one half of the female population in a given country has been abused by a family member or intimate partner, or dangerously neglected in childhood. Violence against women and girls continues to be a global epidemic that kills, tortures, and maims-physically, psychologically, sexually and economically.

More questions than answers exist in the area of sports and violence. However, violence experts frequently express concern about the behavior of athletes in general, and the lack of positive role modeling that exists in sports. Violent behavior by professional and amateur athletes, including assault, rape and domestic violence has been well documented ( Benedict, 1997 ; Benedict & Yaeger, 1999 ).

There are at least two areas of concern for nurses. The first is the experience of violence for youth involved in sports (i.e. win at all costs, intimidation and humiliation surrounding their performance, etc.). Nurses should take the opportunity to educate and intervene with children and teens involved in sports. Education could include principles of respect, good sportsmanship, and conflict management. Perhaps the most important task for nurses is to help parents encourage positive attitudes towards competition and physical activity, recognize signs of anxiety and aggressive behavior, and promote realistic expectations for their child's performance ( Hellstedt, 1988 ).

The second area of concern for nurses is the dynamic of college and professional contact sports athletes who commit violent acts and the failure of society to hold them accountable. Women victimized by professional athletes are highly pressured to keep silent.

a. Domestic violence in the workplace

Domestic violence knows no boundaries. With the increasing number of working women, there is a correspondent increase in the incidence of domestic violence in the workplace. In a study of 118 battered women, Stanley ( 1992 ) found that 69.5% were employed at the time of the abuse. Of that number, 96% stated they experienced problems at work due to their abusive situations. 37% of women personally affected by domestic violence report that the abuse has had an impact on their work performance in the form of tardiness, missed work, a lost job or missed career promotions. ( EDK Associates, 1997 )

Intimate partner violence crosses the boundary of home and work in numerous ways. There are two issues to consider in this category. The first issue surrounds the effect intimate partner violence has on the workplace of the victim/survivor. Absenteeism, security concerns related to abusive partners, productivity, and the emotional impact on co-workers can affect workplaces. The second issue involves perpetrators in the workplace. Perpetrators often use the resources of their place of employment to harass their partner (phone calls, emails, etc.). Furthermore, perpetrators may exhibit the same abusive behavior at work as at home, targeting customers, coworkers, and others.

The total health care costs of family violence are estimated in the hundreds of millions each year, much of which is paid for by the employer ( Pennsylvania Blue Shield Institute, 1992 ).

In a survey commissioned by Liz Claiborne, Inc., Roper Starch Worldwide ( 2000 ) found that corporate leaders have grown more aware of domestic violence as an issue that affects their employees and have become less likely to dismiss the issue's bottom-line impact on business, according to a survey conducted for Liz Claiborne Inc, nine in ten senior executives (91%) believe that domestic violence affects both the private lives and the working lives of their employees (this is up from 44% in a similar study conducted in 1994 by the same company). Yet only 12 percent of corporate leaders surveyed say that corporations should play a major role in addressing the issue-the same percentage as when this question was first posed in 1994. Roper Starch Worldwide (2000) also point out that corporate leaders now rank domestic violence on par with terrorism (68%) as a major issue that affects society. But today, they are also significantly more likely to say that they are aware of employees in their company who have been affected by domestic violence (56% in 2002; 40% in 1994). And, while half thought that domestic violence had a negligible impact on the bottom line in 1994, this percentage has dropped significantly to just one-third (33%) saying so today.

b. Abusive work environments

In addition to the problems presented when domestic violence spills over into the workplace, employers are beginning to address abuse issues within the workplace itself. Often referred to as 'bullying' or 'incivility,' what these behaviors are actually describing is abuse.

Healthcare workplaces are known for harsh, abusive behavior within and between the allied professionals in those environments, particularly physicians and nurses. The Joint Commission on Accreditation of Healthcare Organizations has begun to examine this long-silent issue, and guidelines on "Diagnosing and Treating Workplace Abuse and Neglect in Health Care Organizations" are being written for publication by the American Medical Association. Leadership from the nursing profession will provide needed perspective on the nature of the problem and how to respond to it.

There is a growing body of research pointing to the prevalence of childhood experiences of bullying. Children who are experiencing maltreatment at home are at increased risk for both victimization and perpetration of bullying ( Shields & Cicchetti, 2001 ). Childhood bullying may be an indicator of more extensive family violence and recognize the opportunity for screening and intervention.

Of over 15,000 children surveyed, 10.6% reported bullying others "sometimes" and 8.8% admitted to bullying others once a week or more, with children who bully showing significantly poorer psychosocial adjustment, such as loneliness, difficulty making friends, fighting, smoking, and using alcohol ( Nansel, Overpeck, Pilla, Ruan, Simons-Morton, & Scheidt, 2001 ).

The correlation between exposure to media violence and aggressive behavior has been the subject of numerous studies ( Huesmann, Moise-Titus, Podolski, & Eron, 2003 ). According to the American Academy of Pediatrics ( 1995 ) the vast majority of studies conclude that there is a causal relationship between exposure to media violence and real-life violence. For children exposed to violent behavior in their homes, the effect of media violence is more profound.

Timed reminder

During the segment on statistics, consider using timed sounds to illustrate the frequency of the incidence of abuse, loss of life, or a similar statistic. Use a taped recording of a hand slapping loudly every 15 seconds to signify how often a woman is assaulted by an intimate partner in the U.S. (FBI, 1995 ). Play it as you cover the statistics section.

Participant Cards

As students come into the classroom, give them an index card with a statistic about family violence. Begin discussion of each of the various topics that the statistics address by having the student with the corresponding statistic read it out loud.

Videos

Web sites

Assessment and evaluation resources on the health of work and home environments as it relates to violence and providing direction to employers in seeing their role in addressing this issue:

Respond2, Inc. 1809 Lincoln Ave. St. Paul, MN 55105. 651.699.6565 Deborah Anderson, President

See Appendix B: Family violence: Myths and misconceptions

There is a great deal of misinformation and many false assumptions about individuals in abusive situations. Health care professionals who understand the error of these myths are better equipped to provide care, support, and resources to individuals who indicate they are experiencing abuse.

See Appendix C: Myths About Batterers, Appendix D: The ABCs of Men Who Batter, and Appendix E: Men who Sexually Abuse Children.

Many believe that only 'sick', 'evil' people are abusive. On the contrary, abusers usually lead 'normal' lives in most respects except they believe they are entitled to use violence and abuse to control the lives of their partners and families. Abusers come from every walk of life, every culture, and every socioeconomic level. They do not recognize their behavior as being violence. Often, these unacceptable behaviors are not challenged by society ( Bennett & Williams, 1999 ).

The primary treatment objective for abusers is for the abuser to take responsibility for the abusive behavior and to be held accountable through a variety of measures such as legal consequences and reeducation programs. According to the Standards for Batterers Treatment Programs-Philosophy Statement issued by the Domestic Abuse Project in Minneapolis, effective batterer reeducation includes

For immigrants experiencing family violence, nurses need to consider the cultural and familial context in which the violence occurred and how it is viewed by the victim. This underscores the imperative to engage the services of a professional interpreter when the nurse does not fluently speak the patient's language. Family, friends, and members of the extended community should not be used to assist in these cases. If a professional interpreter is not available on site, a phone interpreter should be utilized. Community pressures and language barriers can keep women trapped and isolated in violent relationships. Fear of immigration sanctions compound this isolation and entrapment.

It is important for nurses to consider the ramifications of actions taken to end the abuse, particularly when involving the legal system. In cases where the patient does not have full legal status in the U.S., contact with local law enforcement and the legal system is advised (without revealing the patient's identity) to ascertain whether the patient would be re-victimized by being reported to immigration.

Victims/survivors should be fully informed of the possible outcomes of various actions they might take to deal with the abusive situation. If a person without legal documentation reports a domestic assault to the police and is later deported to where she had been tortured as a political prisoner, reporting the domestic abuse was more dangerous than not reporting ( Jang, Marin, & Pendleton, 1997 ).

Many immigrants feel as though they must choose between freeing themselves from the abuse and maintaining connection to their family and cultural community (see Appendix F: Immigrant and Refugee Power and Control).

Adolescence is a time when independence, autonomy, sexual identity, and intimacy are mastered-all of which can be disrupted by an abusive relationship. Teens, whose major social goal is to "fit in," are often very reluctant to reveal abuse when it occurs. Some may not even know that they are being abused. Denial is often the only coping mechanism in their repertoire. While they attempt to suppress the cognitive recollection of the abuse, it becomes manifested in their actions. At least 10% will attempt suicide after the abuse ( Pharris & Nafstad, 2002 ). A nurse who develops rapport with the teen and specifically asks about victimization will be able to guide the teen toward healing.

A more effective way of dealing with teen violence is to prevent it. Nurses must look for opportunities to teach teens to differentiate between respectful and violent behavior. Several good resources exist for teaching teens about sexual abuse, healthy dating relationships, and teen dating violence ( Center for the Prevention of Sexual and Domestic Violence, 2000 ; Levy, 1998 ; Levy & Giggans, 1995 ;Quiet Storm Project, 2001 ).

One study of 136 women seen in two rural medical clinics found 20-28% of the women had experienced recent intimate partner abuse ( Johnson & Elliot, 1997 ). Another study of 1693 Minnesota women showed the prevalence of physical, sexual and emotional abuse in rural women to parallel that of their urban counterparts ( Kershner, Long & Anderson, 1999 ).

Rural victims of violence have some unique challenges, including:

( Kershner & Anderson, 2002 , Kershner, Long, & Anderson, 1999 ).

Family violence has been referred to as an "equal opportunity" problem because it happens to people in all demographic categories. Unfortunately, current research on the prevalence, health consequences, and responses to family violence in communities of color in particular has been limited, at best. For example, Torres, Campbell, Campbell, et al. ( 2000 ) point out that "few studies have specifically examined the relative prevalence of abuse during pregnancy in different ethnic groups" (p. 304). Campbell, Sharp, Campbell, and Lopez ( 2002 ) further note that "the theories currently used in domestic violence practice and research generally are one-dimensional in nature and applied uniformly across cultural groups...overall, the applicability of these theories...remains uncertain" (p. 5).

Nurses need to understand the diversity within and between racial/ethnic groups, that family violence happens in a larger cultural context, and the nature of institutional racism experienced daily by people of color. Nurses' responses to patients of color are informed by their own understanding and experiences of racism. The inclination of patients of color to disclose abuse is influenced by their perception of the race and the cultural sensitivity of the individuals and institutions caring for them. They are also influenced by the relevance and accessibility of the resources offered them.

Nurses demonstrate cultural competence through

Regardless of the racial/ethnic background of nurses and patients, the nursing profession and healthcare organizations must prioritize implementation of cultural competency education relevant to the communities in which they operate. This is best accomplished through partnership with community organizations.

People with disabilities have more frequent contacts with health care professionals. It is important not to make any assumptions about people with disabilities and the nature of their relationships with others.

The greater the degree of dependence on others, the greater the likelihood of abuse and exploitation people with disabilities experience ( Pharris, 1999 ). In 1995-96 Berkeley Policy Associates conducted a survey of women with disabilities which found that women with disabilities were more likely to experience abuse by health care professionals and personal assistants, family members, intimate partners, or friends ( Curry & Navarro, 2002 ). Children and elders with disabilities are also more likely to be abused by people responsible for their care.

Factors to consider regarding the abuse of people with disabilities include:

Abuse thrives in silence and isolation. Due to the compulsory secrecy many LGBT people experience about their sexual orientation and relationships, LGBT domestic violence is often referred to as 'the closet within the closet.' "Straight" is the assumed sexual orientation of "a battered woman" in the traditional health care model. LGBT patients fall outside the care model historically designed for non-battered members of the white, heterosexual population. Regardless of sexual orientation, many battering victims commonly face barriers of ignorance and prejudice in receiving supportive, appropriate care and services in medical settings. Battered LGBT patients often face barriers that can literally mean the difference between life and death.

There are many similarities in the dynamics of the abuse of power and control of LGBT and heterosexual relationships. It is important to understand, however, that LGBT domestic violence happens in a cultural context characterized by factors such as:

Nurses can eliminate bias by not assuming the sexual orientation of patients and by using gender neutral language in relationship to the patient's partner. In accordance with the Code of Ethics for Nurses ( ANA, 2001 ), nurses must provide equally sensitive care to each patient.

In families where there is intimate partner violence, children are at high risk for being abused. There is a significant correlation between intimate partner abuse and abuse of children.

Children's responses to witnessing adult domestic violence vary considerably depending on the child's age, gender, level of violence in the home, degree of the child's exposure, whether or not they are abused, and the presence of other risk and protective factors. Some children have such resilience that they are able to cope with the chaos of a violent home in constructive ways. While children are affected by violence in their lives, not all experience long-term negative consequences.

Studies of children who witness domestic abuse have shown that the experience can have long-lasting emotional, behavioral, cognitive, spiritual, and physical effects. Children in violent homes may experience harmful circumstances

Kolbo ( 1996 ) points out that children from violent homes exhibit more aggressive and delinquent behavior, and more withdrawn, anxious behaviors compared to children from non-violent homes. They also perform significantly below their peers in academics, school sports and social activities. Studies have shown that children exposed to domestic violence have a significantly higher rate of psychiatric problems than other children. Exposure to violence in the home has been found to be one of the most significant predictors of an adolescent's later use of violence in the community ( Singer, Mille, Guo, Slovak & Frierson, 1998 ). Childhood exposure to domestic violence is the major predictor for being a perpetrator or victim of domestic violence in adulthood.

Behaviors vary in different age groups:

Child protective service and health care professionals often interpret children witnessing of domestic violence as a failure to protect on the part of the mother who is being battered. It is critical to remember, however, that this line of reasoning does not recognize that the perpetrator is responsible for creating the dangerous environment in the first place, and must be held accountable for stopping the violence. Generally speaking, the children are safe when the mother is safe.

Abusers use the threat or actual killing of animals as a way to establish or maintain control of their victim(s). Maiming or killing a pet is more than an act of aggression against the animal. Animal abuse is a likely indicator of abuse of family members. In the case of children who beat, torture, or mutilate animals, such behavior suggests serious psychopathology ( Robin, 1999 ).

Abusers who use drugs and alcohol are more likely to inflict injury on family members ( Grisso, Schwarz, Hirschinger, Sammel, Brensinger, et al, 1999 ). However, while substance abuse may be a contributing factor, no evidence has been found to support a causal relationship between substance abuse and family violence. Not all batterers abuse substance and not all those who use substances batter. Abusers often use alcohol as an excuse for their violence and as a way to avoid responsibility for their behavior. Substance abuse treatment will not stop the violent behavior. Shared characteristics of alcoholism and family violence are denial, minimization, isolation, and intergenerational patterns.

Coping through substance abuse is a common response to family violence. Some women who have been battered also have substance abuse problems; however, this is not the reason they are being battered. Women who abuse substances have experienced more violence as children and experience significantly more abuse as adults compared to the general population ( Miller, Downs, & Gondoli, 1989 ; Miller & Downs, 1993 ).

A review of the literature does not reveal a causal relationship between serious and persistent mental illness and the perpetration of abuse and violence. However, research indicates that intimate partner violence and child abuse increase the risk for mental health problems, particularly post traumatic stress disorder and depression, in those who have been abused ( Golding, 1999 ).

Explaining family violence in an addiction framework is problematic because battering is neither an addiction nor a symptom of addiction; they are separate problems requiring separate solutions. Their relationship is sometimes contributory, but not causal. Equating them is dangerous for the victim and does not hold the perpetrator accountable. Furthermore, "co-dependency", an extension of addiction theory, is refuted by the following:

Caregiver stress is commonly used to explain why a person is abused by a family member on whom they are dependent for care.

Three problems with naming this dynamic caregiver stress include:

Family violence violates human rights, has a major impact on health and causes great suffering. Physical and sexual abuse is illegal; emotional abuse is unethical and robs people of their basic rights to dignity and individuality.

Nursing practice is driven by a unique set of ethical principles focused on patient advocacy and empowerment. The 2001 American Nurses Association Code of Ethics for Nurses includes statements that say nurses should

Ethical principles that apply to family violence include: