My interest in DV began when I was hired as a nurse consultant to be part of a 10 year chart review of women who died within 360 days of being pregnant. When young women of childbearing age die, they seldom die of one thing, they die of everything. If we can intervene and prevent this stressor in her life, than we may save her life. The case that haunted me. Fever of unknown origin. Burn on her upper arm that did not match her story. Backing into an iron. This burn was treated, but her infection got worse and she died. Her explanation of the treated burn did not match the shape and size of the injury. On autopsy another infected burn was found in the bathing suit area. She told no one about this and died protecting her abuser. Don’t misunderstand the until death do us part!
Abuse should never be fasionable.
He isolates, escalates and promises never to do it again, if she will only take him back. Abuse is about power and control, not love. The cost of DV exceeds $4.1 billion in direct medical and mental health care services. Victims of DV account for 22-35% of all women seeking emergency medical care. $150 million is spent annually on the medical care of women’s injuries. As many as 324,000 women each year experience violence during pregnancy with deleterious effects on both the woman and her fetus including LBW and prematurity for the baby, with a 25% increased risk of attempted suicide as well as substance abuse for the mother.
One teen got three of his buddies to constantly instant message his victim pretending to be the boyfriend in 6 hour shifts, so she could not sleep. She was attacked when she could not continue responding. Teens do not have the life experience to know that abuse is not love. Love should not hurt.
DV can start any time, but it is particularly evident in times of stress…a lost job, economic difficulties and debts and of course, pregnancy. Men can be abused but the most likely to be abused are women, with 1 in 4 women likely to be beaten or raped by a partner during her lifetime. On the average day in America, 3 women are killed by a current or former partner.
Why don’t women report abuse: shame, his promises that it will never happen again. Abuse is NEVER a one time occurance. 2013 the Violence Against Women Act was signed (national).
One in 6 women and one in 33 men have been victims of a completed or attempted rape. MDCH investigates about 60 cases a year of women who died within a year of being pregnant. I currently serve on the medical Review committee of the Maternal Mort Study. We determine whether a case was pregnancy related or pregnancy associated or not related at all. If you are in the wrong place at the wrong time and your car is struck by a 16 wheeler, then it had nothing to do with having been pregnant. But there are other cases that are not this clear cut. Death certificates and pregnancy can be correlated, non fatal violence is hard to determine, because many women do not report abuse.
We know it increases with drugs, and alcohol. We know it increases in severe economic downturns. We know that some men are taught to “control their wives” Rule of thumb in early America. You can beat your wife with a stick that is no larger than your thumb.
But why should he stop? His partner treats him like a king. The chances are good that he will escalate the frequency and the violence of his attacks and isolate her from family and friends. She is alone, and he tells her no one will believe her, because he is such a nice guy. He may even send her flowers at work. What a nice guy, they say. He goes to every doctor’s appointment with her to make sure she does not tell. He is charming to the staff, but he may make disparaging jokes about how clumsy she is, particularly now that she is pregnant. You may find her looking at him as she answers you to make sure she gives the right answers. He has convinced her she is stupid and can’t make it on her own. He tells her she is a bad mother. After awhile she believes what he says because he has isolated her. He says he can’t stop. He says its your fault that you made him do it, and he will never do it again, but these are the lies he wants you to believe. Love should not hurt (Oprah), The greatest predictor of future behavior is what has gone on before (Dr. Phil) and Believe him the first time when he shows you who he is (Maya Angelou). Who he is, is when he hits her, not when he is begging her to stay.
What is abuse, It is the systematic pattern of abusive behaviors, occurring over a period of time, that may become more frequent and severe. The behaviors are done for the purpose of control, domination and /or coercion (Schornstein, 1997, p. 3). An intimate partner is someone with whom you are or have been intimately involved. Abuse can happen to anyone. He can’t help himself she says. It’s not his fault. I made him do it. Abusers can stop. If his mother comes to the door while he is abusing you, what will he do? He will answer the door. He can stop! Abuse is a learned behavior. It is learned in the home of origin by watching a parent be abused. Not everyone chooses to become an abuser who drinks, does drugs or is under stress. He says he can’t help himself and it is NEVER his fault! Newspaper account, pregnant women, hit her stomach, then he hit her in the face causing her frontal sinus bones to fracture. They had to put her back together with metal plates. He originally told police she hit herself, but changed his testimony in court. Remember, Abusers abuse, because they can. Who wouldn’t like to be treated like a king?
He isolates her from family and friends. She feels she is alone.
One young mother told her nurse that her boyfriend had hit her while she was pregnant, but she was not abused, because she “fought back”. She went on to say that he would never hurt the baby. Her nurse asked her who she thought he was hurting when he punched her belly?
The pie shaped headings are the tactics used to maintain power and control over the another.
Fundamentalist beliefs of any religion may subordinate the woman to her husband as “head of the household”. He may convince her that she has to follow his orders to be true to her religion and her marriage vows. Women from other countries, who have become more independent, may be at greater risk from violence, especially if they have been perceived as being seen and not heard in the traditional culture. Women may be viewed as property by men who have recently immigrated or who have lived here for generations.
I came up with the B. S. Cycle of violence preparing for this talk. I thought it was a useful way to remember the trajectory violence can take. Not everyone who is abused gets all of it, but all of those who are abused get some of it. According to Jackie Campbell, violence needs to be stopped at the shoving stage. Why do men abuse? Because they can. That does not mean that women cannot be abusers, but most abuse is perpetrated by men. Why does he do it? Did she push his buttons? She made him do it. He can’t control his anger. If he just would not drink, then things would be fine. He promised never to do it again. He would not beat me if he did not love me. If I am just good enough, will he stop? The only behavior we can control is our OWN! I am frequently asked, “Will he change?” The answer is yes. He will probably get worse. He can get better, but only with treatment. He is responsible for his behavior. As nurses what is our responsibility? We have to document all injuries. That means we check the whole body. Pictures are best to go along with descriptions of injuries and how she said she got them. Beware of stories that do not match bruises or burns. Document what you saw and what she said.
If you are unable to read English, drive a car or have money for public transportation, you will have difficulty getting help for abuse. Many immigrants are dependent upon family and friends to take them to health care appointments. If we let them translate for her, they will know the secret. These are also people the abused woman does not wish to know about her abuse, and they may well report back to her abuser.
This is the time when we have healthy young women come for routine prenatal care. Walk-ins have a reason for not coming for care. Some studies found that pregnant women were over 60% more likely to suffer violence than those who were not pregnant. Asking once on a check off form is not enough. The abuse may not start until later in the pregnancy, if you only ask once, you may miss the opportunity to find out what is going on. Asking at every visit may convince the woman that you are really interested in the answer and you will offer her help. Remember, homicide is the leading cause of death for pregnant women.
Starting at age 14 we need to assess every woman at every interaction with the health care system. Document in writing and with photographs or drawings when suspected abuse has occurred. She may have run into a door for her black eye, but she is more likely to have run into a fist. Document what she said happened. Be sure to check her whole body for abuse. The areas covered by a bathing suit are often targeted, because they are hidden under clothes. “ I assess all my clients for violence, I am wondering if this could be happening to you?” or “Many of my clients tell me they are being hurt; when I see bruises like yours, I always ask about abuse” If you don’t ask, she won’t tell.
She has to have a plan. When you share phone numbers and safety planning information, give her options about where he is unlikely to look for documents. Hide the shelter numbers in Shoes, tampon box, back of refrigerator. Document, document, document. Take pictures of her injuries.
I was at a conference where a woman said she had to leave her abuser 8 times before she finally stayed away. Sometimes leaving is practicing to see if she can survive without him. Women have a six times greater risk of harm when they leave their abuser. It is when she is most likely to be killed.
We file form 3320 for children who we suspect are being abused. We report on the elderly and those who are handicapped. Hospitals and pharmacists are mandated to report a person who has suffered a wound or injury with a deadly weapon or by other means of violence. A woman must give her consent for a referral for counseling that is covered by a third party payer. Her partner may see the statement for services which would put her in danger. Also, her insurance can be cancelled if it is states she is suffering from IPV. When you document suspected abuse, you are creating a legal document that she may need in the future. It is shows a pattern of abuse and will be useful in filing for personal protection, divorce or custody hearings.
What if I am wrong? One of my students asked before we filed a 3200. I said, “And what if you’re not?” Funding for the Violence Against Women Act 2013: provides resources to law enforcement and nonprofit organizations; strengthens the capabilities of tribes to respond to violence against Native American women; increases access to support services for lesbian, gay, bisexual and transgender victims of domestic violence; assists in providing funding to ensure that rape kits are promptly tested; and increases safety on college campuses by improving reporting and prevention programs.
When she has a plan to leave, she needs to take a bag with the important papers she has, and she needs a place to go. That may mean leaving with the clothes on her back if the situation is likely to be volatile. Is there room for her and her children at the shelter? Let her use your phone, so if he finds her phone, he does not have a head start on where to look for her or use a national hotline. She can use a computer at a library or in your office. Help is available 24/7.
This number works. I called it to make sure. They have interpreters in 260 languages. This website also works, but remind her to use a computer other than her own.
Flowers for the grave are a gift too late and do nothing to help the person abused. Don’t misunderstand “until death do us part”.
FamilyFamilyViolence:Violence:A GrowingA GrowingPublic HealthPublic HealthConcernConcernMary M. Conklin, JD, MSN, RNMary M. Conklin, JD, MSN, RNMargaret M. Gorman, PhD, RNCMargaret M. Gorman, PhD, RNCmconklin3615@email@example.com@firstname.lastname@example.org
Who is Family?Who is Family? A spouse or former spouse Someone with whom the person residesor has resided Someone the person has or had dated Continued…….
Who is Family?Who is Family? Someone the person is or has had asexual relationship Someone who is related or was formerlyrelated to by marriage Someone with whom the person has achild
What is Abuse ?What is Abuse ? The Physical, Emotional/PsychologicalThe Physical, Emotional/Psychologicaland Economic Control of Another.and Economic Control of Another. Abuse is about Power and Control andAbuse is about Power and Control andnot Love.not Love.
Physical AbusePhysical Abuse Pushing and ShovingPushing and Shoving Pulling HairPulling Hair PunchingPunching BitingBiting Sexual CoercionSexual Coercion
Emotional AbuseEmotional AbuseBelittling/Put DownsBelittling/Put DownsTauntingTauntingThreats to Her or Her FamilyThreats to Her or Her FamilyDestruction of Things She LovesDestruction of Things She Loves
Economic AbuseEconomic Abuse Demanding an Accounting of EveryDemanding an Accounting of EveryPenny SpentPenny Spent Absolute control over their MoneyAbsolute control over their Money
Digital or CyberDigital or CyberStalkingStalking Teens can be victims of someone whoTeens can be victims of someone whodemands they respond with a picturedemands they respond with a picturewith a clock to prove they are not out withwith a clock to prove they are not out withsomeone else.someone else. Teen’s parents may not be aware theirTeen’s parents may not be aware theirteen is a victim until they are harmed.teen is a victim until they are harmed.
Who Can Be Abused ?Who Can Be Abused ? Young or OldYoung or Old Male or FemaleMale or Female Straight or GayStraight or Gay Rich or PoorRich or Poor Educated or IlliterateEducated or Illiterate Anyone, Anytime, Anywhere,Anyone, Anytime, Anywhere,
Violence AgainstViolence AgainstWomenWomen 1 in 5 murders in the U.S. are DV related1 in 5 murders in the U.S. are DV related Women abused during pregnancy have aWomen abused during pregnancy have athreefold increase in risk of beingthreefold increase in risk of beingmurderedmurdered In the U.S., the percentage of women killedIn the U.S., the percentage of women killedby an intimate partner rose from 40% toby an intimate partner rose from 40% to45% over a 10-year period45% over a 10-year period Data significantly underestimateData significantly underestimateprevalence of DVprevalence of DV
AssaultAssault M Civ JI 115.01 Definition An assault is any intentional, unlawfulthreat or offer to do bodily injury toanother by force, under circumstanceswhich create a well-founded fear ofimminent peril, coupled with the apparentpresent ability to carry out the act if notprevented.
BatteryBattery M Civ JI 115.02 Definition A battery is the willful or intentionaltouching of a person against thatperson’s will [by another / by an object orsubstance put in motion by anotherperson].
95,024 Offenses of DV95,024 Offenses of DVincluding Rape wereincluding Rape wereReported in 2011Reported in 2011 Michigan Uniform Crime Reports 2011Michigan Uniform Crime Reports 2011
Human Costs of AbuseHuman Costs of Abusein Michiganin Michigan 3,290 cases of rape in 20113,290 cases of rape in 2011 576 children were under 10 years old576 children were under 10 years oldMichigan Uniform Crime Report (2011)Michigan Uniform Crime Report (2011)
WHY ?WHY ? No single factor explains why one personand not another behaves in a violentmanner. Violence is a complex problemrooted in the interaction of many factors Biological, Social, Cultural, Economicand Political,” (WHO, 2002).
He Can Stop!He Can Stop!Past Behavior PredictsPast Behavior PredictsFuture Behavior!Future Behavior!
Abuser CharacteristicsAbuser Characteristics Charming at firstCharming at first Quick CommitmentQuick Commitment IsolationIsolation Verbal AbuseVerbal Abuse ThreatsThreats Cruelty to animals and childrenCruelty to animals and children
Abuse Is A ChoiceAbuse Is A Choice Drugs and Alcohol do not CauseDrugs and Alcohol do not CauseAbuseAbuse Stress does not Cause AbuseStress does not Cause Abuse His Partner did not Cause the AbuseHis Partner did not Cause the Abuse Abuse is Learned BehaviorAbuse is Learned Behavior Abusers, Abuse to get what they WantAbusers, Abuse to get what they Want
Characteristics ofCharacteristics ofPeople in AbusivePeople in AbusiveRelationshipsRelationships Traditional Female Roles orTraditional Female Roles orCharacteristicsCharacteristics Low Self-Esteem or Self-BlameLow Self-Esteem or Self-Blame Depression or VulnerabilityDepression or Vulnerability Lack of Social SupportLack of Social Support
Myths of AbuseMyths of Abuse He Promised Never to do it AgainHe Promised Never to do it Again I Pushed his ButtonsI Pushed his Buttons If I am Just Good Enough he will StopIf I am Just Good Enough he will Stop I can Help him get BetterI can Help him get Better He Would Never Hurt the BabyHe Would Never Hurt the Baby It’s My FaultIt’s My Fault
Subordination of theSubordination of theAbused PersonAbused Person CultureCulture ReligionReligion Women Viewed as PropertyWomen Viewed as Property Vulnerable ElderlyVulnerable Elderly DependentDependent ChildrenChildren Vulnerable Mentally IncompetentVulnerable Mentally Incompetent
Gorman’s B. S.Gorman’s B. S.Trajectory ofTrajectory ofViolenceViolence Building--ShoutsBuilding--Shouts Bullying--ShovingBullying--Shoving Battering--She’s to blameBattering--She’s to blame Begging--Sorry, Sorry, SorryBegging--Sorry, Sorry, Sorry Believing--Shame--flowers at workBelieving--Shame--flowers at work Burying--Suffering has ended--flowersBurying--Suffering has ended--flowersagain; this time for the groundagain; this time for the ground
Cultural Barriers toCultural Barriers toCareCare ReligionReligion Family NormsFamily Norms Traditions of SilenceTraditions of Silence The Man is the Head of the HouseholdThe Man is the Head of the Household
Structural Barriers toStructural Barriers toCareCare TransportationTransportation Economics—Financial DependenceEconomics—Financial Dependence Communication—No Phone orCommunication—No Phone orComputer AccessComputer Access Locked in the HouseLocked in the House
Domestic Violence Is ADomestic Violence Is ACrimeCrime Majority of states categorize DV as aMajority of states categorize DV as amisdemeanormisdemeanor DV may also be a FelonyDV may also be a Felony
Pregnancy IncreasesPregnancy IncreasesDVDV Abuse often begins in PregnancyAbuse often begins in Pregnancy Missed AppointmentsMissed Appointments Late or Inadequate Prenatal CareLate or Inadequate Prenatal Care LBW and PrematurityLBW and Prematurity Homicide is the Leading Cause ofHomicide is the Leading Cause ofDeath for Pregnant WomenDeath for Pregnant Women
DV During PregnancyDV During Pregnancy Most women abused before pregnancy willMost women abused before pregnancy willbe abused during pregnancybe abused during pregnancy Abuse may happen for first time duringAbuse may happen for first time duringpregnancypregnancy Peaks during the first trimesterPeaks during the first trimester Pregnant adolescents are abused at higherPregnant adolescents are abused at higherrates than are adult womenrates than are adult women Risk of fetal injury is highRisk of fetal injury is high
Intentional Injury to A PregnantIntentional Injury to A PregnantWomanWomanIs Guilty of A Felony if both A and BIs Guilty of A Felony if both A and BApplyApply (a)The person intended to cause a miscarriageor stillbirth by that individual or death or greatbodily harm to the embryo or fetus, or acted inwanton or willful disregard of the likelihood thatthe natural tendency of the persons conduct isto cause a miscarriage or stillbirth or death orgreat bodily harm to the embryo or fetus. (b) The persons conduct resulted in amiscarriage or stillbirth by that individual ordeath to the embryo or fetus.
Plan and InterventionPlan and Intervention ABCDESABCDES of caring for abused womenof caring for abused women AloneAlone BelieveBelieve ConfidentialityConfidentiality DocumentationDocumentation EducationEducation SafetySafety
Assessing for DVAssessing for DV AWAY FROM HER ABUSERAWAY FROM HER ABUSER Every Woman at Every VisitEvery Woman at Every Visit Assess the Bathing Suit AreaAssess the Bathing Suit Area Document in WritingDocument in Writing Photograph injuriesPhotograph injuries Inpatients Referred to Social ServicesInpatients Referred to Social Services
How to Ask About DVHow to Ask About DV Frame the questionsFrame the questions We ask all our clients if someone is hurtingWe ask all our clients if someone is hurtingthem, someone in their family or close tothem, someone in their family or close tothem. No one has the right to hurt you. I willthem. No one has the right to hurt you. I willask you about your relationships, and if youask you about your relationships, and if youare experiencing violence, we haveare experiencing violence, we haveresources and referrals for you.resources and referrals for you.
Three Questions toThree Questions toAskAsk Have you been emotionally or physicallyHave you been emotionally or physicallyhurt by someone close to you? Y or Nhurt by someone close to you? Y or N Within the last year have you been hit,Within the last year have you been hit,slapped or otherwise physically hurt byslapped or otherwise physically hurt bysomeone? Y or Nsomeone? Y or N If yes, by whom and how many times?If yes, by whom and how many times? TOTAL______TOTAL______
Safety PlanningSafety Planning You Don’t Leave Something to go toYou Don’t Leave Something to go toNothingNothing Provide her InformationProvide her Information Give her ChoicesGive her Choices BELIEVE HERBELIEVE HER Document What You DidDocument What You Did Document What She SaidDocument What She Said
Leaving theLeaving theRelationshipRelationship Leaving is a ProcessLeaving is a Process She Needs to Know She can SurviveShe Needs to Know She can SurviveWithout HimWithout Him The Greatest Danger is when SheThe Greatest Danger is when SheLeavesLeaves Only She can Decide When to Leave,Only She can Decide When to Leave,OR IF TO LEAVE!OR IF TO LEAVE!
Care For SexualCare For SexualAssaultAssault Collaborative careCollaborative care Sexual assault examination-Same GenderSexual assault examination-Same Gender Preservation of dignity during the examinationPreservation of dignity during the examination HistoryHistory Collection of evidenceCollection of evidence DocumentationDocumentation Physical examination and laboratory testsPhysical examination and laboratory tests Immediate careImmediate care
Prevention is worth aPrevention is worth aPound of CurePound of Cure Violence against women is a major socialViolence against women is a major socialand health care problemand health care problem Thousands of livesThousands of lives Billions of dollars in direct and indirect healthBillions of dollars in direct and indirect healthcare costscare costs DV includes physical, sexual, emotional,DV includes physical, sexual, emotional,psychological, and economic abusepsychological, and economic abuse
Key PointsKey Points Cultural influences regarding violentCultural influences regarding violentbehaviors and relationships sensitize thebehaviors and relationships sensitize thenurse to the special needs of womennurse to the special needs of womenfrom various ethnic groupsfrom various ethnic groups Battering affects young, middle-aged,Battering affects young, middle-aged,and elderly of all races; alland elderly of all races; allsocioeconomic, educational, religioussocioeconomic, educational, religiousgroups, and pregnant womengroups, and pregnant women
Key PointsKey Points Follow-up and collaborative careFollow-up and collaborative careimportant in all instances of abuseimportant in all instances of abuse Public Health Providers need to bePublic Health Providers need to beknowledgeable about reportingknowledgeable about reportingrequirements and available communityrequirements and available communityservice for women who have beenservice for women who have beensexually assaultedsexually assaulted
Mandatory ReportingMandatory Reporting ChildrenChildren ElderlyElderly VulnerableVulnerable BUT OtherBUT Other Adults Make Their OwnAdults Make Their OwnDecisionsDecisions
Reporting Abuse,Reporting Abuse,NeglectNeglectIf you suspect abuse or neglect, call 855-444-3911 anytime day or night. This toll-free phone number allows you to report abuse orneglect of any child or adult to the Michigan Department of Human Services.
Why Doesn’t SheWhy Doesn’t SheLeave?Leave? I will not leave him, because we live withI will not leave him, because we live withhis parents. I have nowhere to go.his parents. I have nowhere to go.My parents are old and sick. I lost my jobMy parents are old and sick. I lost my jobwhen they found out I was pregnant.when they found out I was pregnant.I want to leave, but I do not haveI want to leave, but I do not have papers,papers,and I do not speak English. Atand I do not speak English. At leastleastwith him, the kids have food,with him, the kids have food, clothesclothesand a warm bed.and a warm bed.
Help Her Make theHelp Her Make theCallCall National Domestic Violence Hotline atNational Domestic Violence Hotline at::1-800-799-SAFE (7233)1-800-799-SAFE (7233)or TTY for the Deaf:or TTY for the Deaf:1-800-787-32241-800-787-3224 www.ndvh.orgwww.ndvh.org www.michigan.gov/domesticviolencewww.michigan.gov/domesticviolence
Abuse should never be fashionableAbuse should never be fashionableQuestions?Questions?