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Health care professionals are the first line response to many domestic violence survivors. In this capacity, they must be prepared to identify, assess, and assist victims with safety planning, and provide referrals to needed services. Health care providers must recognize that the emergency room is only one of many health care settings where domestic violence survivors are found. Almost every medical discipline is confronted at some point with the tragic results of domestic violence.

All who provide services to domestic violence survivors, both adults and children, must provide education as well as prevention and intervention strategies to offset the impact of the trauma of violent homes. Not only must safety, support and a wide array of services be available to victims, but offenders must receive prompt attention, assessment, education and treatment if society is to realize success in eliminating violence from America's homes.

At the conclusion of this program, participants, will be able to:

Included in this report is a listing of additional national and state resources that are available to assist the victims of domestic violence.

Domestic Violence Definition

Domestic violence is one form of intimate partner violence. The Centers for Disease Control and Prevention (CDC) defines intimate partner violence as "actual or threatened physical or sexual violence, or psychological and emotional abuse, directed toward a spouse, ex-spouse, current or former boyfriend or girlfriend, or current or former dating partner." Other terms used to describe domestic violence include domestic abuse, spouse abuse, courtship violence, battering, marital rape, and date rape.

On January 6, 2006, President George W. Bush signed into law the reauthorization of the Violence Against Women Act, H.R. 3402. Among other provisions of this law, it would continue to encourage collaboration among law enforcement, judicial personnel, and public and private service providers to victims of domestic and sexual violence; address the special needs of victims of domestic and sexual violence who are elderly, disabled, children, youth, and individuals of ethnic and racial communities, including Native Americans; provide emergency leave and long-term transitional housing for victims; make provisions gender neutral; and require studies and reports on the effectiveness of approaches used for certain grants in combating domestic and sexual violence.

The term "Domestic Violence" under this law includes felony or misdemeanor crimes of violence committed by a current or former spouse of the victim, by a person with whom the victim shares a child in common, by a person who is cohabitating with or has cohabitated with the victim as a spouse, by a person similarly situated with a spouse of the victim under the domestic or family violence laws of the jurisdiction- receiving grant monies, or by any other person against an adult or a youth victim who is protected from that person's acts under the domestic or family violence laws of the jurisdiction.

First passed in 1994, the Violence Against Women Act was the first federal law to comprehensively address violence against women. It was re-authorized in 2000, continuing the essential work begun earlier and adding important services for immigrant, rural, disabled and older women.

The new re-authorization will expand and extend the law for five years, with funding appropriated at approximately $3.9 billion. Congress must determine actual authorization levels each year, however, and does not always fund programs at the levels in the appropriation.

The Centers for Disease Control and Prevention (CDC) in October 2005 released the results of the first study that identifies the health care costs and impact of domestic violence incidents, where men as well as women are victims.

Domestic violence which affects more than 32 million Americans each year; with more than 2 million injuries and approximately 1,300 deaths. This type of violence includes physical, sexual, or psychological harm to another by a current or former partner or spouse.

The study, co-authored by Ileana Arias, PhD, director of CDC's National Center for Injury Prevention and Control, and published in the journal Violence and Victims, found the health care costs associated with each incident were $948 in cases where women were the victims and $387 in cases where men were the victims. The study also found that domestic violence against women results in more emergency room visits and inpatient hospitalizations, including greater use of physician services than domestic violence where men are the victims.

"This study clearly shows the true impact of domestic violence," said Arias. "Domestic violence, especially against women, causes a range of emotional, physical, and financial harm for victims and their families. We need to continue our efforts to prevent this type of violence, including broadening our focus to also address the needs of men who are victims."

CDC researchers determined health care costs by looking at mental health services; the use of medical services such as emergency departments, inpatient hospitals, and physician services; and losses in productivity such as time off from work, childcare or household duties because of injuries. The average medical cost for women victimized by physical domestic violence was $483 compared to $83 for men; mental health services costs for women was $207 compared to $80 for men; while productivity losses were similar at $257 for women and $224 for men.

Phaedra Corso, PhD, a CDC economist and the study's other author, noted that a previous CDC study using 1995 data that was published in 2003 provided estimates of the total direct health care costs of domestic violence. According to Corso, that study estimated the direct health care costs associated with domestic violence to be around $4.1 billion. In addition, the study estimated that domestic violence caused an estimated $1.8 billion in productivity losses associated with injuries and premature death.

"Unfortunately, we believe the estimates using 1995 data are conservative because many cases of domestic violence are not reported," Corso said. "In today's dollars, the health care and productivity costs are likely to be much greater. Ultimately, the economic burden of domestic violence impacts all of society. Hospitals, workplaces, and communities must devote and be able to provide resources to treating and assisting victims, while the criminal justice system, mental health providers, employers and the community must bear a variety of other costs."

Common Myths About Family Violence

Almost all family violence experts seem to agree that domestic violence is much more common than ever realized. The National Committee to Prevent Child Abuse reported in 1994 that over three million children experienced some form of abuse (physical, sexual, neglect, or emotional abuse). Straus and Gelles reported in 1986 that 28% of American couples experience at least one act of violence during their marriages, 16% experience at least one act of violence per year, and 5% experience severe violence in any given year. Even these data are considered conservative.

While some studies do provide evidence that there appears to be a higher incidence of violence in families at or below the poverty line (Straus et al, 1980, cite a violence rate 5 times that of families above the line), and a later study indicated "blue-collar" husbands more violent (13.4%) than "white-collar" husbands (10.4%), this does not lead to the erroneous assumption often heard, that poor familes are always violent, or that only poor families are violent.⁽³⁾ This is not true. Poor people who lack other support or resources are much more likely to turn to police or social agencies more often than families who have money.

This is a dangerous generalization to make as it tends to make one accept the intergenerational pattern of abuse as the complete explanation, in and of itself, to predict behavior. Most of the research has been done on self reports and in retrospective research which relies on adult memories and perceptions. Also, there is not often a comparison group of nonviolent adults giving self reports. The data suggest that child witnesses to violence, or victims of abuse are more likely to be abusive, but not predetermined to be so.

Criticisms of battered women, blaming the victims for not "just leaving", lead to conclusions such as they must really enjoy being beaten, are nags, or drunks, or are mentally ill, therefore they, and not the batterers are at fault. Attention needs to focus not on why they stay but why "he abuses".

While alcohol or drug abuse does figure in a majority of violent incidents, it cannot be said to be the cause of the abuse. Many abusers batter their partners whether drunk or sober. Many batterers never use alcohol or drugs. Being drunk or stoned often serves as an excuse for the behavior and another way to deny personal responsibility for battering.

The average battering relationship lasts about 6 years, the same length of time as the average marriage. Physical violence does not preclude the presence of love and intimacy, nor does it spell the end of the relationship. Many victims call police to make the violence stop, not to end the relationship. Children learn very young, that the people who love them, may also hit them.

Intimate partner violence (IPV) is a serious, preventable public health problem affecting more than 32 million Americans. According to a Justice Department analysis of intimate-partner violence in 2001, the latest year for which statistics are available, 85 percent of the victims are women.

The term "intimate partner violence" describes physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

IPV can vary in frequency and severity. It occurs on a continuum, ranging from one hit that may or may not impact the victim to chronic, severe battering. Repeated abuse is also known as battering.

The National Center for Injury Prevention and Control lists the following four main types of intimate partner violence:

1. Physical violence is 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.
2. Sexual violence is divided into three categories: 1) use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed; 2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act, e.g., because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and 3) abusive sexual contact..
3. Threats of physical or sexual violence use words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm.
4. Psychological/emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. Psychological/emotional abuse can include, but is not limited to, humiliating the victim, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. It is considered psychological/emotional violence when there has been prior physical or sexual violence or prior threat of physical or sexual violence.

IPV is a serious problem that is common in our society. Violence by an intimate partner is linked to both immediate and long-term health, social, and economic consequences. Factors at all levels-individual, relationship, community, and societal-contribute to the perpetration of IPV. Preventing IPV requires a clear understanding of those factors, coordinated resources, and empowering and initiating change in individuals, families, and society.

The term "survivor" is often applied to those who have experienced intimate partner violence. The CDC recommends that health care workers and advocates may use it instead of "patient" or "victim" because it is a more empowering term.

Elder Abuse

Intimate Partner Violence is not isolated within any one demographic group it affects all classes and races and every age group. One fact is indisputable: as the population of 50-plus Americans increases, so will the number of victims of abuse in that vulnerable demographic. Until recently even experts on domestic violence used to think the problem tapered off by age 50. That opinion became accepted wisdom because few older women show up at shelters or call police.

The National Committee for the Prevention of Elder Abuse defines elder abuse as any form of mistreatment that results in harm or loss to an older person. It is generally divided into the following categories:

• Physical abuse is physical force that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint.
• Sexual abuse is non-consensual sexual contact of any kind with an older person.
• Domestic violence is an escalating pattern of violence by an intimate partner where the violence is used to exercise power and control.
• Psychological abuse is the willful infliction of mental or emotional anguish by threat, humiliation, or other verbal or nonverbal conduct.
• Financial abuse is the illegal or improper use of an older person's funds, property, or resources.
• Neglect is the failure of a caregiver to fulfill his or her care giving responsibilities. Self-neglect is failure to provide for one's own essential needs.

Although estimates vary, it is generally believed that 4-6% of the elderly are abused. According to the National Incidence Study on Elder Abuse, approximately 450,000 elderly experienced abuse in 1996 nationwide. If self-neglect is included, the number is 551,000.

The personal losses associated with abuse can be devastating and include the loss of independence, homes, life savings, health, dignity, and security. Victims of abuse have been shown to have shorter expectancies than non-abused older people.

According to the National Committee for the Prevention of Elder Abuse, an association of advocates, researchers, and professionals, the problem of domestic violence in later life divides into three main types.

1. The first scenario involves a new relationship. No matter how mature they are, no matter how well they think they know their new partner, intimates can be in for a terrible surprise. It's an all-too-common problem, say experts. "We see many second, or even third, marriages where she had a perfectly wonderful first marriage but ends up with a real loser," says Pat Holland, coordinator of the Older Abused Women's Program at the Milwaukee Women's Center, which last year opened two rooms specifically for older clients in its shelter. "A lot of times she's so embarrassed she doesn't want anybody to know."
2. A second category, encompassing a seemingly growing number of victims, is known as "late-onset domestic violence," in which a long, ordinary marriage unexpectedly leads to a coda of brutality and fear. There may have been a strained relationship or emotional abuse earlier that got worse when a partner aged. When abuse begins, it is likely to be triggered by retirement, the changing role of family members, sexual changes, or disability. For example, one spouse's failing health-the onset of incontinence, for example-can trigger verbal or physical violence by his or her partner.

Brain impairments common in old age, like those brought on by stroke, alcoholism, or Alzheimer's disease, can also herald aggressive behavior in otherwise placid marriages. A percentage of Alzheimer's patients turn suspicious, irritable, or even physically violent toward their loved ones. In one study nearly 60 percent of people caring for a spouse with dementia report the patient has turned to some form of aggressive behavior.

3. A third category-perhaps the most heart-rending cases of all-involves violence that begins in early marriage and continues for decades without ever triggering notice. Advocates call this phenomenon "domestic violence grown old" and a study published in the Journal of Elder Abuse & Neglect notes it is by far the most common sort. These women were missed by the battered women's movement, which began establishing shelters and safe houses in the late 1970s and today operates more than 2,500 programs and facilities across the country. Now, in later life, battered women are no more likely to reach out for help than in their youth.

The directors of women's centers and programs for the aging are now scrambling to find ways to reach this population. But traditional responses, like shelters and hot lines, don't seem to be making the critical connection with older victims. Around the country, according to a survey by the National Clearinghouse on Abuse in Later Life, few shelters promote themselves to older women or are equipped to handle their special needs, from accessible facilities to segregation from the many young children who often turn shelters into daycare centers.

"There's a lot more shame and embarrassment" among older victims, explains Sharon Youngerman, director of a well-known battered women's program in Orange Park, Florida, called Quigley House, which closed its elder shelter last year, finding that older women preferred the support they got from younger battered women in the main shelter. "We're talking about people raised in a generation when the wife took care of the family; she was basically raised to do what her husband said. He was the breadwinner, and if she didn't like it, she had to basically buck up and be quiet. So talking about it is admitting that they failed-that they displeased the husband."

"The elderly population is totally secretive about this," says Ann Nevin, a counselor in private practice in Colorado who treats older victims. "A lot of it has to do with the cultural and social mores established for the people who grew up in the '20s and '30s: you married for life and you stuck things out."

Although it occurs less often, men also fall prey to domestic violence. But while an estimated 15 percent of all the victims of intimate-partner violence are men, the number of reported woman-on-man incidents is negligible. The reason may be that no matter how bad the abuse, men in their prime are typically able to withstand the assaults of women. A more likely explanation is that men simply are unwilling to report that they've been assaulted by a woman.

But as they grow older, men can become vulnerable. Sometimes, but not frequently, their abused spouses might simply be turning the tables. An unscientific sampling suggests that another likely scenario involves same-sex or late-life relationships turned abusive.

It can be extremely difficult for older gay people to be candid about their relationship to their abuser. "This is the generation that was institutionalized, discriminated against, battered by society" for being homosexual, says Loree Cook-Daniels, founder of the American Society of Adult Abuse Professionals and Survivors.

A late-life relationship with a younger person can also lead to the victimization of an older man. At the Hebrew Home's Harry and Jeanette Weinberg Center for Elder Abuse Prevention, officials recall a case of an older man who took a much younger foreign bride, only to find her manipulating his medications. He was admitted to the hospital numerous times before finding his way into their shelter. "It appears she was just in it for the immigration status," says Daniel Reingold, the Hebrew Home's president. The Weinberg Center is helping arrange a divorce and a restraining order.

Just as there is no consensus on exactly how widespread the problem is, or how to locate its victims, there is limited agreement on the causes of elder domestic violence and how to prevent it from happening. Craig Mayfield, 57, a facilitator who runs court-mandated abusers' groups in Milwaukee, says older batterers can be more resistant to the counseling program than younger ones. "For the older men, who have been accustomed to the social messages that required women to stay at home, be housewives, never questioning the man's authority, that may still be the way they see things," he says. But their motive is no different from that of younger perpetrators. "Men batter women because they can," says Mayfield. "What they think they're doing is controlling their women. That's what we focus on-breaking their need to control things."

Sexual violence is a serious problem that affects millions of people every year. Its victims are at increased risk of being abused again. Sexual violence perpetrators are also at increased risk of perpetrating again.

Statistics about sexual violence vary due to differences in how it is defined and how data is collected. Sexual violence data usually come from police, clinical settings, nongovernmental organizations, and survey research.

Available data from the Department of Justice greatly underestimate the true magnitude of the problem. Rape is one of the most underreported crimes. In 2002, only 39% of rapes and sexual assaults were reported to law enforcement officials. While not an exhaustive list, here are some statistics on the occurrence of sexual violence.

• About 2 out of 1000 children in the United States were confirmed by child protective service agencies as having experienced sexual assault in 2003.
• Among high school youth nationwide:
• About 9% of students reported that they had been forced to have sexual intercourse.
• Female students are more likely than male students to report sexual assault (11.9% vs. 6.1%).
• Overall, 12.3% of Black students, 10.4% of Hispanic students, and 7.3% of White students reported that they had been forced to have sexual intercourse.
• Among college students nationwide, between 20% and 25% of women reported experiencing completed or attempted rape.
• Among adults nationwide:
• More than 300,000 women (0.3%) and over 90,000 men (0.1%) reported being raped in the previous 12 months.
• One in six women (17%) and one in thirty-three men (3%) reported experiencing an attempted or completed rape at some time in their lives.
• Rape usually occurs more than once. Among adults who report being raped, women experienced 2.9 rapes and men experienced 1.2 rapes in the previous.

Perpetrators

Many people believe that sexual assault occurs only in dangerous neighborhoods and is perpetrated by strangers. Research shows, however, that most sexual assaults and rapes are committed by someone the victim knows. Among victims aged 18 to 29, two-thirds had a prior relationship with the offender. During 2000 the Department of Justice reported that about six in ten rape or sexual assault victims stated the offender was an intimate, other relative, a friend or an acquaintance.

A study of sexual victimization of college women showed that most victims knew the person who sexually victimized them. For both completed and attempted rapes, about 9 in 10 offenders were known to the victim. Most often, a boyfriend, ex-boyfriend, classmate, friend, acquaintance, or co-worker sexually victimized the women. Anyone can be a victim of sexual assault. Avoiding "dangerous" places will not necessarily protect someone from being sexually assaulted because sexual assaults can happen anywhere, even in the home or workplace.

The National Center for Victims of Crime reported that there is no typical domestic violence perpetrator, but psychologists have identified some common characteristics. Many abusers suffer from low self-esteem, and their sense of self and identity is tied to their partner. Therefore, if abusers feel they are somehow losing the victim, either through separation, divorce, emotional detachment, or pregnancy (fearing victims will replace love for them with love for a child), they will lash out. If victims "leave" through any of these methods, abusers feel they are losing power, control, and their self-identity. This is why it is particularly dangerous for victims during periods of separation or divorce from their partner. Abusers will often do anything to maintain control and keep the victim under control. This dynamic also makes escalating violence inevitable, as many victims must become emotionally unavailable, or must physically leave, in order to survive.

While the public may think of domestic violence abusers as out of control, crazy, and unpredictable, the contrary is most often true. Use of psychological, emotional, and physical abuse intermingled with periods of respite, love, and happiness are deliberate coercive tools used to generate submission. Abusers may violently assault, then minutes later offer words of regret. Many will buy gifts of flowers, candy and other presents in order to win favor and forgiveness. This creates a very confusing environment for victims. Abusers may say they will never harm their partners again, and promise to obtain help or counseling. Often, these promises are only made to prevent victims from leaving. Without getting help, the violence will most likely recur.

The violence used by abusers is controlled and manipulative. Victims often can predict exactly when violence will erupt. Many law enforcement officers have commented on their surprise at finding significant evidence of a violent incident, a harmed victim, and a composed perpetrator casually speaking with officers as if nothing occurred.

Finally, many victims describe domestic violence perpetrators as having a "Jekyll and Hyde" personality. Abusers often experience dramatic mood swings of highs and lows. They may be loving one minute, and spiteful and cruel the next. Abusers are frequently characterized by those outside the home as generous, caring, and good, and behave drastically differently in their home environment. Perpetrators of domestic violence are rarely violent to those outside of their domicile.

Health Behaviors

Some researchers view the following health behaviors as both consequences of sexual violence and factors that increase a person's vulnerability to being victimized again in the future.

• Engaging in high-risk sexual behavior including:
• Unprotected sex
• Early sexual initiation
• Choosing unhealthy sexual partners
• Having multiple sex partners
• Trading sex for food, money, or other items
• Using or abusing harmful substances, including:
• Smoking cigarettes
• Drinking alcohol
• Driving after drinking alcohol
• Taking drugs

Certain groups are at risk for IPV victimization or perpetration.

Victimization

• Women are more likely to be victims of sexual violence than men: 75% of the victims of rape and sexual assault are women and 25% are men.
• Sexual violence starts very early in life. More than half of all rapes of women (54%) occur before age 18; 22% of these rapes occur before age 12. For men, 75% of all rapes occur before age 18, and 48% occur before age 12.
• Prevalence of IPV varies among race. American Indian and Alaskan Native women are significantly more likely (34%) to report being raped than African American women (19%) or White women (18%).
• Women in college who use drugs, attend a university with high drinking rates, belong in a sorority, and drank heavily in high school are at greater risk for rape.

Perpetration

• Most perpetrators of sexual violence are men. Among acts of sexual violence committed against women since the age of 18, 100% of rapes, 92% of physical assaults, and 97% of stalking acts were perpetrated by men. Sexual violence against men is also mainly male violence: 70% of rapes, 86% of physical assaults, and 65% of stalking acts were perpetrated by men.

Relationship between Victim and Perpetrator

• In 8 out of 10 rape cases, the victim knows the perpetrator.
• A national survey found that 34% of women were victims of sexual coercion by a husband or intimate partner in their lifetime.
• Of people who report sexual violence, 64% of women and 16% of men were raped, physically assaulted, or stalked by an intimate partner. This includes a current or former spouse, cohabitating partner, boyfriend/girlfriend, or date.

Vulnerability Factors for Victimization and Risk Factors for Perpetration

The statistics on sexual violence are biased by underreporting and the emphasis on more overtly violent sexual assaults. Underreporting is due to victims' embarrassment, shame, fear, feelings of discomfort and mistrust about the official(s) to whom an assault is reported.

Despite the underestimation of the true magnitude of the problem, research has increased understanding of factors that make some populations more vulnerable to sexual violence victimization and more at risk for sexual violence perpetration.

Vulnerability factors increase the likelihood that a person will suffer harm. Risk factors increase the likelihood that a person will cause harm. However, neither vulnerability nor risk factors are direct causes of sexual violence - they are contributing factors to sexual violence. Vulnerability factors for victimization and risk factors for perpetration comprise a combination of individual, relational, community and societal factors.

Vulnerability Factors for Victimization

• Prior history of sexual violence. Women who are raped before the age of 18 are twice as likely to be raped as adults, compared to those without a history of sexual abuse.
• Gender. Women are more likely to be victims of sexual violence than men: These findings may be influenced by the reluctance of men to report sexual violence.
• Young age. Sexual violence victimization starts very early in life. More than half of all rapes of women (54%) occur before age 18; 22% of these rapes occur before age 12. For men, 75% of all rapes occur before age 18, and 48% occur before age 12.Young women are at higher risk of being raped than older women.
• Drug or alcohol use. Binge drinking and drug use are related to increased rates of victimization.
• High-risk sexual behavior. As with drug/alcohol use, researchers are trying to understand the complex relationships between sexuality and sexual violence - their causality, directionality, and other etiologic factors that increase vulnerability for victimization are not well understood. Some researchers believe that engaging in high-risk sexual behavior is both a vulnerability factor and a consequence of childhood sexual abuse. Youths with many sexual partners are at increased risk of experiencing sexual abuse.
• Poverty. Poverty may make the daily lives of women and children more dangerous (e.g. walking alone at night, less parental supervision). It may also make them more dependent on men for survival and therefore less able to control their own sexuality, consent to sex, recognize their own victimization or to seek help when victimized. These issues increase their vulnerability to sexual victimization. In addition, poor women may be at risk for sexual violence because their economic (and, often, educational) status necessitates that they engage in high-risk survival activities, for example trading sex for food, money, or other items. Poverty also puts women at increased risk of intimate partner violence, of which sexual violence is often one aspect.
• Ethnicity/culture. American Indian and Alaskan Native women are more likely (34%) to report being raped than African American women (19%), White women (18%) or Hispanic women (15%).

Risk Factors for Perpetration

Individual Factor

• Alcohol and drug use
• Coercive sexual fantasies
• Impulsive and antisocial tendencies
• Preference for impersonal sex
• Hostility towards women
• Hypermasculinity
• Childhood history of sexual and physical abuse
• Witnessed family violence as a child

Relationship Factors

• Association with sexually aggressive and delinquent peers
• Family environment characterized by physical violence and few resources
• Strong patriarchal relationship or familial environment
• Emotionally unsupportive familial environment

Community Factors

• Lack of employment opportunities
• Lack of institutional support from police and judicial system
• General tolerance of sexual assault within the community
• Settings that support sexual violence
• Weak community sanctions against sexual violence perpetrators

Societal Factors

• Poverty
• Societal norms that support sexual violence
• Societal norms that support male superiority and sexual entitlement
• Societal norms that maintain women's inferiority and sexual submissiveness
• Weak laws and policies related to gender equity
• High tolerance levels of crime and other forms of violence

Protective Factors

• Protective factors may lessen the likelihood of sexual violence victimization or perpetration, and exist at individual, relational, community, and societal levels. Although less is known about protective factors, the literature suggests measures to prevent potential perpetrators. Some examples for youth are connectedness with school, friends and adults in the community, and emotional health.

Why Victims May Stay

Very few individuals would become involved in a relationship they knew to be violent. Domestic violence has subtle origins. What starts out as love, courtship and concern, may turn into domination, forced adherence to rigid sex roles and obsessive jealousy. Victims are not masochists. They do not enjoy being hurt, abused, battered and controlled. Victims may stay with someone who is abusing them for various reasons which include:

• Fear of the abuser;
• Love;
• Threats to harm the victim, loved ones or pets;
• Threats of suicide;
• Believing the abuser will take their children;
• Religious reasons;
• Believing the abuser will change;
• Self-blame;
• Limited financial options;
• Believing that violence is normal;
• Believing in the sanctity of marriage and the family;
• Limited housing options;
• Blaming the abuse on alcohol, financial pressures, or other outside factors;
• Low self-esteem;
• Fear of the unknown, of change;
• Isolation;
• Embarrassment and shame;
• Believing no one can help;
• Cultural beliefs;
• Denial; and
• Pressure from friends and family to stay.

Domestic Violence Survivors Options

The National Center for Victims of Crime recommends that domestic violence survivors contact a local domestic violence program. These programs are in many communities around the country and can provide: counseling and support groups; information about legal options, the criminal justice system, and social services; shelter; attorney referrals; vocational counseling; safety planning; and case advocacy. Programs will assist victims regardless of their decision to stay in, or leave, the relationship.

In addition, they should create a comprehensive safety plan. With assistance from a victim service professional, victims should create an individualized plan for safety in all situations, including a checklist of necessary items to take when leaving an abusive situation.

Finally they should consider legal options. In every state, domestic violence is a crime. For information on criminal penalties for abusers, and protections for victims through the criminal justice system, victims should contact local law enforcement or prosecutor's office. Reporting domestic violence incidents may raise safety concerns, so this option should be discussed with a victim service professional. Whether victims choose to report, it may be helpful to document evidence of abuse (i.e., pictures, witness statements, tape recordings), to be used in criminal proceedings, or in custody or divorce hearings. Every state also has a process for obtaining civil protective orders (also known as no contact orders, or restraining orders) that prohibit contact between an abuser and a victim. For more information on civil protective orders, victims should contact a local domestic violence program.

Occurrence

According to the Department of Health and Human Services Data, the confirmed number of U.S. child maltreatment cases in 2002 are available from child protective service agencies; but these data are generally considered underestimates:

• 906,000 children in the United States were confirmed by child protective service agencies as being maltreated.
• Among children confirmed by child protective service agencies as being maltreated, 61% experienced neglect; 19% were physically abused; 10% were sexually abused; and 5% were emotionally or psychologically abused.
• An estimated 1,500 children were confirmed to have died from maltreatment; 36% of these deaths were from neglect, 28% from physical abuse, and 29% from multiple maltreatment types.

Shaken-baby syndrome (SBS) is a form of child abuse affecting between 1,200 and 1,600 children every year. SBS is a collection of signs and symptoms resulting from violently shaking an infant or child (National Center on Shaken Baby Syndrome 2005).

Consequences

Children who experience maltreatment are at increased risk for adverse health effects and behaviors as adults-including smoking, alcoholism, drug abuse, eating disorders, severe obesity, depression, suicide, sexual promiscuity, and certain chronic diseases.

• Maltreatment during infancy or early childhood can cause important regions of the brain to form improperly, leading to physical, mental, and emotional problems such as sleep disturbances, panic disorder, and attention-deficit/hyperactivity disorder.
• About 25% to 30% of infant victims with SBS die from their injuries. Nonfatal consequences of SBS include varying degrees of visual impairment (e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments.
• Victims of child maltreatment who were physically assaulted by caregivers are twice as likely to be physically assaulted as adults.
• As many as one-third of parents who experienced maltreatment in childhood may victimize their own children .
• Direct costs (judicial, law enforcement, and health system responses to child maltreatment) are estimated at $24 billion each year. The indirect costs (long-term economic consequences of child maltreatment) exceed an estimated $69 billion annually.

Groups at Risk

Children younger than 4 years are at greatest risk of severe injury or death. In 2003, children younger than 4 years accounted for 79% of child maltreatment fatalities, with infants under 1 year accounting for 44% of deaths.

Risk and Protective Factors

A combination of individual, relational, community, and societal factors contribute to the risk of child maltreatment. Although children are not responsible for the harm inflicted upon them, certain individual characteristics have been found to increase their risk of being maltreated. Risk factors are contributing factors-not direct causes.

Examples of risk factors:

• Disabilities or mental retardation in children that may increase caregiver burden
• Social isolation of families
• Parents' lack of understanding of children's needs and child development
• Parents' history of domestic abuse
• Poverty and other socioeconomic disadvantage, such as unemployment
• Family disorganization, dissolution, and violence, including intimate partner violence
• Lack of family cohesion
• Substance abuse in family
• Young, single nonbiological parents
• Poor parent-child relationships and negative interactions
• Parental thoughts and emotions supporting maltreatment behaviors
• Parental stress and distress, including depression or other mental health conditions
• Community violence

Protective factors are the opposite of risk factors and may lessen the risk of child maltreatment. Protective factors exist at individual, relational, community, and societal levels.

Examples of protective factors:

• Supportive family environment
• Nurturing parenting skills
• Stable family relationships
• Household rules and monitoring of the child
• Parental employment
• Adequate housing
• Access to health care and social services
• Caring adults outside family who can serve as role models or mentors
• Communities that support parents and take responsibility for preventing abuse

Power and Control

Though there are no typical victims of domestic violence, abusive relationships do share similar characteristics. In all cases, the Mayo Clinic has found that the abuser aims to exert power and control over his partner.

"A lot of people think domestic violence is about anger, and it really isn't," says Diana Patterson, a licensed social worker and violence prevention coordinator at Mayo Clinic, Rochester, Minn. "Batterers do tend to take their anger out on their intimate partner. But it's not really about anger. It's about trying to instill fear and wanting to have power and control in the relationship."

But anger is just one way that an abuser tries to gain authority. The batterer may also turn to physical violence - kicking, punching, grabbing, slapping or strangulation, for example. The abuser may also use sexual violence - forcing their partner to have sexual intercourse or to engage in other sexual activities against their will.

In an abusive relationship, the abuser may use varying tactics to gain power and control, including:

• Children as pawns. Accusations of bad parenting, threatens to take the children away, uses the children to relay messages, or threatens to file a report with children's protective services.
• Coercion and threats. Threatens to hurt other family members, pets, children or self.
• Denial and blame. Denies that the abuse occurs and shifts responsibility for the abusive behavior onto the other partner. This may leave them confused and unsure of themselves.
• Economic abuse. Controls finances, refuses to share money, makes the partner account for money spent and doesn't want them to work outside the home. The abuser may also try to sabotage their work performance by forcing them to miss work or by calling them frequently at work.
• Emotional abuse. Uses put-downs, insults, criticism or name-calling to make them feel bad about themselves.
• Intimidation. Uses certain looks, actions or gestures to instill fear. The abuser may break things, destroy property, abuse pets or display weapons.
• Isolation. Limits contact with family and friends, requires permission for them to leave the house, doesn't allow them to work or attend school, and controls their activities and social events. The abuser may ask where they have been, track their time and whereabouts, or check the odometer on their car.
• Power. Makes all major decisions, defines the roles in the relationship, is in charge of the home and social life, and treats the partner like a servant or possession.

Signs of Abuse

It may not be easy to identify abuse. An abusive relationship can start subtly. The abuser may criticize appearance or may be unreasonably jealous. Gradually, the abuse becomes more frequent, severe and potentially life-threatening.

"It's important to know that these relationships don't happen overnight," says Patterson. "It's a gradual process - a slow disintegration of a person's sense of self."

Typically each time the abuse occurs, it worsens, and the cycle shortens. Breaking this pattern of violence alone and without help is difficult.

"When you live in an environment of chaos, stress and fear, you start doubting yourself and your ability to take care of yourself," says Patterson. "It can really unravel your sense of reality and self-esteem." So it's important to recognize that they may not be in a position to resolve the situation on their own. They may need outside help. Without help, the abuse will likely continue. Leaving the abusive relationship may be the only way to break the cycle.

In an emergency situation, they should call 911 or local law enforcement agency. If they aren't in immediate danger, consider contacting one of the following resources:

• National Domestic Violence Hotline. Provides crisis intervention and referrals to in-state or out-of-state resources, such as women's shelters or crisis centers.
• Doctor or hospital emergency room. Treats any injuries and refers them to safe housing and other local resources.
• Local women's shelter or crisis center. Typically provides 24-hour, emergency shelter for both the survivor and their children, advice on legal matters, advocacy and support services, and evaluation and monitoring of abusers.
• Counseling or mental health center. Most communities have agencies that provide individual counseling and support groups to women in abusive relationships. Be wary of anyone who advises couples or marriage counseling. This isn't appropriate for abusive relationships.
• Local court. The district court can help obtain a court order, which legally mandates the abuser stay away from them or face arrest. These are typically called orders for protection or restraining orders. Advocates are available in many communities to help them complete the paperwork and guide them through the court process.

How the Health Care Provider Can Help

Health care providers and clinicians who accept the challenge and responsibility of caring for abuse victims must recognize domestic violence as a major health care problem, understand the power and control issues which drive partner abuse, accept the victims' choices non-judgmentally, and support the empowerment of battered victims.

Sensitivity and Awareness

The Women's Health Center at UCLA has developed recommended guidelines for the healthcare provider. These call for reassuring the patient s/he is not alone and does not deserve to be treated this way. Be careful not to imply patient is to blame (i.e. by asking what prompted the abuse or suggesting couple's counseling).

Be aware of the following:

• Patients may be scared of seeking care because they do not want police involvement.
• Some patients may fear reporting for other reasons (i.e. immigration status). There are many potential barriers to leaving an abusive situation (i.e. threats from the batterer, fear of financial instability, failure of police and others to effectively intervene, hope the relationship can work)

American Medical Association Guidelines

The American Medical Association has developed Diagnostic and Treatment Guidelines On Domestic Violence. The AMA recommends that domestic violence and its medical and psychiatric ramifications are sufficiently prevalent to justify routine screening of all women patients in emergency, surgical, primary care, pediatric, prenatal, and mental health settings. Because some women may not initially recognize themselves as "battered," the health care provider should routinely ask all women direct, specific questions about abuse. Such questions may be included in the social history, past medical history, review of systems, or history of present illness, as appropriate.

Although women may not bring up the subject of abuse on their own, many will discuss it when asked simple, direct questions in a nonjudgmental way and in a confidential setting. The patient should be interviewed alone, without her partner present. The health care provider should make an opening supportive statement, such as: "Because abuse and violence are so common in women's lives, I've begun to ask about it routinely."

Even if the patient does not respond at the time, the fact that a provider is concerned and believes that battering is a possibility will make an impression. The health care provider's concern about abuse validates her feelings and reinforces her capacity to seek help when she feels ready and able to do so.

Routine questions about violence not only identify women who are currently being abused but also serve to assess the safety of women who have been battered in the past and to heighten the awareness of those who have not been in abusive relationships. Routine assessment is particularly important for women who have left a violent relationship; leaving an abusive partner or finalizing a divorce may increase her risk for abuse. The health care provider should provide appropriate follow-up during legal proceedings, and assess the woman's need for emergency shelter or other resources.

A medical encounter may provide the only opportunity to stop the cycle of violence before more serious injuries occur, and intervention begins by gathering information. Providing the woman with a different kind of experience-one in which she is respected and taken seriously; one that lets her know she doesn't deserve to be abused; one that offers the possibility of support and safety, and one that encourages her own choices and decision making is, in itself, therapeutic and an important step. Questions about domestic violence should be asked in the health care provider's own words and in a nonjudgmental way.

Here are some examples of recommended questions:

• Are you in a relationship in which you have been physically hurt or threatened by your partner? Have you ever been in such a relationship?
• Are you (have you ever been) in a relationship in which you felt you were treated badly?

In what ways?

• Has your partner ever destroyed things that you cared about?
• Has your partner ever threatened or abused your children?
• Has your partner ever forced you to have sex when you didn't want to? Does he ever force you to engage in sex that makes you feel uncomfortable?
• We all fight at home. What happens when you and your partner fight or disagree?
• Do you ever feel afraid of your partner?
• Has your partner ever prevented you from leaving the house, seeing friends, getting a job, or continuing your education?
• You mentioned that your partner uses drugs/alcohol. How does he act when he is drinking or on drugs? Is he ever verbally or physically abusive?
• Do you have guns in your home? Has your partner ever threatened to use them when he was angry?

Diagnosis and Clinical Findings

Injury: Episodes of physical assault characterize abusive relationships. Health care providers should especially consider the possibility of assault when the woman's explanation of how an injury occurred does not seem plausible or when there has been a delay in seeking medical care.

Common types of injury include:

• Contusions, abrasions, and minor lacerations, as well as fractures or sprains
• Injuries to the head, neck, chest, breasts, and abdomen
• Injuries during pregnancy
• Multiple sites of injury
• Repeated or chronic injuries

Medical findings: The stress of living in an ongoing abusive relationship may cause any of the following:

• Chronic pain, psychogenic pain, or pain due to diffuse trauma without visible evidence
• Physical symptoms related to stress, chronic post-traumatic stress disorder, other anxiety disorders, or depression. Examples are:

• Sleep and appetite disturbances
• Fatigue, decreased concentration, sexual dysfunction
• Chronic headaches
• Abdominal and gastrointestinal complaints
• Palpitations, dizziness, paresthesias, dyspnea
• Atypical chest pain
• Gynecologic problems, frequent vaginal and urinary tract infections, dyspareunia, pelvic pain
• Frequent use of prescribed minor tranquilizers or pain medications
• Frequent visits with vague complaints or symptoms without evidence of physiologic abnormality

Many practitioners have noted that chronic illnesses such as asthma, seizure disorders, diabetes, arthritis, hypertension, and heart disease may be exacerbated or poorly controlled in women who are being abused.

Sexual coercion and assault are common expressions of domestic violence. Assessment for sexual abuse and rape should be addressed in the sexual or social history taken during routine primary care visits, in discussions of birth control and safer sexual practices and in evaluations during gynecologic and obstetric visits.

Pregnancy: Pregnancy is a particularly perilous time for an abused woman. Not only is their health at risk, but also the health of their unborn child. Abuse can begin or may increase during pregnancy. Because of the risk to the mother and fetus, assessment for abuse should be incorporated into routine prenatal and postpartum care. Presentations include:

• Injuries, particularly to the breasts, abdomen, and genital area, or unexplained pain.
• Substance abuse, poor nutrition, depression, and late or sporadic access to prenatal care
• "Spontaneous" abortions, miscarriages, and premature labor

Mental Health/Psychiatric Symptoms: Assessment for domestic violence should be included as a routine part of psychiatric intakes and evaluations. The stress of domestic violence may aggravate psychiatric disorders. Psychiatric symptoms of abuse include the following:

• Feelings of isolation and inability to cope
• Suicide attempts or gestures
• Depression
• Panic attacks and other anxiety symptoms
• Alcohol or drug abuse
• Post-traumatic stress reactions and/or disorder

Routine assessment of domestic violence in the patient's family is important for both men and women in alcohol and drug rehabilitation programs. Nearly 75% of all wives of alcoholics have been threatened, and 45% have been assaulted by their addicted partners.

Control in a Relationship: An abusive partner's use of control within a violent relationship may result in:

• Limited access to routine and/or emergency medical care
• Noncompliance with treatment regimens
• Not being allowed to obtain or take medication
• Missed appointments Lack of independent transportation, access to finances, ability to communicate by phone Failure to use condoms or other contraceptive methods
• Not being told by a partner that he is infected with HIV or other sexually transmissible diseases

Behavioral Signs: Battered women exhibit a variety of responses to the stress of ongoing abuse; such patients may appear frightened, ashamed, evasive or embarrassed. A battered woman may believe she deserves the abuse because the abuser tells her so, and she may take responsibility for his violence to maintain some sense of control over her situation.

Other findings may include the following:

• Partner accompanies patient, insists on staying close, and answers all questions directed to her
• Reluctance of a patient to speak or disagree in front of her partner
• Intense irrational jealousy or possessiveness expressed by partner or reported by patient
• Denial or minimization of violence by partner or by patient
• Exaggerated sense of personal responsibility for the relationship, including self-blame for her partner's violence

Interventions

Once abuse is recognized, a number of interventions are possible, but even if a woman is not ready to leave the relationship or take other action, the health care provider's recognition and validation of her situation is important. Silence, disregard, or disinterest convey tacit approval or acceptance of domestic violence. In contrast, recognition, acknowledgment, and concern confirm the seriousness of the problem and the need to solve it. Optimal care for the woman in an abusive relationship also depends on the health care provider's working knowledge of community resources that can provide safety, advocacy, and support.

The injury or complaint that precipitated the health care encounter requires evaluation and appropriate treatment. In addition, the health care provider should ask about the patient's use of pain, sleeping, or anti-anxiety agents. Psychiatric problems, including severe depression, panic disorder, suicidal tendencies or substance abuse, may hinder the battered woman's ability to assess her situation or take appropriate action. When serious psychiatric conditions are present, an appropriate treatment plan includes psychiatric evaluation and treatment. On the other hand, emotional, behavioral, and cognitive symptoms of abuse can be misinterpreted as psychiatric in origin. Health care providers must make sure that the mental health professional to whom they refer the patient is sensitive to these issues.

Alcohol or drugs may be used to rationalize violent behavior. Perpetrators and family members may insist that substance abuse is the problem. Evidence indicates that while substance abuse and violent behavior frequently coexist, the violent behavior will not end unless interventions address the violence as well as the addiction. Similarly, mental illness is rarely the cause of domestic violence, although mental illness in a batterer can lead to loss of control and increased frequency and severity of violence. Treating the mental illness alone will not end the violence. Both issues must be addressed.

Couples' counseling or family intervention is generally contraindicated in the presence of domestic violence. Attempts to implement family therapy in the presence of ongoing violence may increase the risk of serious harm. The first concern must be for the safety of the woman and her children.

Often women are not the only victims at home: Child abuse has been reported to occur in many families where adult domestic violence occurs. In situations when children are also being abused, coordinated liaisons between advocates for victims of domestic violence and child protective service agents should be used to ensure the safety of both the mother and her children. Otherwise, the reporting and investigation of alleged child abuse may increase the mother's risk of abuse.

Patient Safety

It is imperative that the health care provider inquire about a battered woman's safety before she leaves the medical setting. The severity of current or past injury is not an accurate predictor of future violence; and many women minimize the danger they face. After assessing the situation, plans for the woman's safety should be discussed before she leaves the health care provider's office. Various options should be considered:

• Does she have friends and family with whom she can stay?
• Does she want immediate access to a shelter?
• If none is available, can she be admitted to the hospital?
• If she doesn't need immediate access to a shelter, give her written information about shelters and other resources if it is safe to do so.
• Does she need immediate medical or psychiatric intervention?
• Does she want immediate access to counseling to help her deal with the stress caused by the abuse?
• Does she want to return to her partner, with a follow-up appointment at a later date?
• Does she need referrals to local domestic violence organizations?

Information and Resources

If the patient feels it is safe to do so, provide her with written information (including phone numbers) on legal options, local counseling and crisis intervention services, shelters, and community resources. In addition, educational materials on domestic violence in waiting areas and examination rooms may help patients identify violence as a personal health problem.

National organizations on domestic violence and many local and state battered women's programs have information available for use in health care provider offices. Local domestic violence shelters and statewide domestic violence programs are frequently listed in the phone book. They can help with housing, information about legal rights, welfare applications, and counseling (including peer groups and counseling for children). They may have brochures for distribution to women patients that address issues and list local resources. Many programs offer these services without charge.

Barriers to Identification

Patient Barriers

Many women are reluctant or unable to seek help. Some are literally held captive and not allowed out of the house. Others may not have money or means of transportation. If they do come to a health care provider's office, they may have to leave before they are seen, rather than risk further abuse for "getting home late." Childhood experiences of physical or sexual abuse, or witnessing domestic violence, may make it more difficult for a battered woman to recognize a relationship as abusive and to take steps to protect herself. Cultural, ethnic or religious background may also influence a woman's response to abuse and her awareness of viable options. Other reasons for not mentioning abuse include:

• Fear that revelation will jeopardize her safety
• Shame and humiliation at the way she is being treated
• Thinking she deserved the abuse and is not deserving of help
• Feeling protective of her partner. He may be her sole source of love and affection when he is not abusive and may provide the financial support for her and her children.
• Lack of awareness that her physical symptoms are caused by the stress of living in an abusive relationship
• Belief that her injuries are not severe enough to mention

Because the experience of abuse is so degrading and humiliating, a woman may be reluctant to discuss it with someone who may not take her seriously, who may discount her experience, who may perceive her as deserving the abuse, or blame her for staying with her abuser. She may fear that reporting the abuse will jeopardize her safety and destroy her means of support; she may stay in the relationship hoping that the situation will improve.

Her partner may not always be abusive and this gives her hope that he will change.

Health Care Provider Barriers

Until recently, health care providers rarely addressed issues of abuse and violence, even when the signs or symptoms were present. There are many reasons why health care providers may avoid asking about abuse and why it may seem difficult to do so initially. Among these are:

• Lack of awareness of the prevalence, means of identification, or severity of the problem and lack of recognition of the social and psychological costs of abuse
• Thinking it is not a health care provider's place to intervene, or that the woman must have provoked the abuse
• Believing identification of abuse and referral for services is not part of the health care provider's role
• Not knowing how to intervene or help even if a woman is recognized as being battered
• "Blaming the patient" and feeling frustrated or angry if the woman doesn't leave her partner (She becomes the problem for being noncompliant with the health care provider's timetable)
• Disbelief because the alleged assailant is present and seems very concerned and pleasant
• Concern that discussing psychosocial issues will take an overwhelming amount of time
• Difficulty dealing with the feelings evoked by listening to a woman describe what has been done to her. The health care provider may feel helpless or inadequate if he or she can't "do something" to "fix" the situation.

Documentation

Thorough, well-documented medical records are essential for preventing further abuse. Furthermore, they provide concrete evidence of violence and abuse and may prove to be crucial to the outcome of any legal case. If the medical record and testimony at trial are in conflict, the medical record may be considered more credible. Records should be kept in a precise, professional manner and should include the following:

• Chief complaint and description of the abusive event, using the patient's own words whenever possible rather than the health care provider's assessment. "My husband hit me with a bat" is preferable to "Patient has been abused."
• Complete medical history
• Relevant social history
• A detailed description of the injuries, including type, number, size, location, resolution, possible causes, and explanations given. Where applicable, the location and nature of the injuries should be recorded on a body chart or drawing.
• An opinion on whether the injuries were adequately explained
• Results of all pertinent laboratory and other diagnostic procedures
• Color photographs and imaging studies, if applicable
• If the police are called, the name of the investigating officer and any actions taken

In addition to complete written records, photographs are particularly valuable as evidence. The health care provider should ask the patient for permission to take photographs. Imaging studies also may be useful. State laws that apply to the taking of photographs usually apply to xrays as well.

• When possible, take photographs before medical treatment is given
• Use color film, along with a color standard
• Photograph from different angles, full body and close-up
• Hold up a coin, ruler, or other object to illustrate the size of an injury
• Include the patient's face in at least one picture
• Take at least two pictures of every major trauma area
• Mark photographs precisely as soon as possible with the patient's name, location of injury, and names of the photographer and others present
• For medical records to be admissible in court the health care provider should be prepared to testify:

Legal Developments

Protection of Victims

Today every state has some form of legislation designed to offer protection to victims of domestic violence. Some states have placed additional duties on police, requiring them to make arrests in certain cases, accompany women to their homes to collect children and belongings, and inform them of their legal rights. The AMA recommends that health care providers need to be aware of state laws and of the services available in their community for abuse victims.

The legal remedies available to battered women vary from state to state and these laws are changing rapidly. Advocacy programs often can explain to women the legal options that are available, and can help them access the legal system. The most common civil action in domestic violence cases is a protective order, injunction, or restraining order, which is a court order that directs the batterer to stop abusing the victim. In some states, the court may have the authority to order a batterer to leave a shared residence, receive counseling, make support payments, pay medical bills, or take other action. Depending on the jurisdiction, police also may be required to arrest abusers who violate protective orders. In any event, a woman's safety must be continually reassessed since a protective order does not guarantee it.

Criminal actions against batterers may include prosecution for assault, battery, aggravated assault or battery, harassment, intimidation, or attempted murder. Historically, abused women often have been unable to pursue such charges against their spouses, and even today they may encounter police who are reluctant to take action, prosecutors who downgrade charges, and courts that are not receptive to such claims. Some states have adopted specific provisions that criminalize domestic abuse, but the lack of explicit laws does not necessarily mean that criminal prosecution is unavailable.

A common remedy is for a court to issue an order of protection (also known as a protective order) that orders the alleged abuser to stop abusing or harassing someone else. In addition, the orders often will direct the abuser to stay away from the spouse, the spouse's home, or place of work. If the person continues to abuse his or her spouse (or another person protected by the order), the abuser can be charged with a criminal violation of the order in addition to being charged with other offenses, such as assault and battery. Penalties include fines and incarceration.

The domestic violence statutes in most states apply not only to physical attacks, but also to other types of conduct. Some examples of conduct that could be considered domestic violence: creating disturbance at a spouse's place or work, harassing telephone calls, stalking, surveillance, and threats against a spouse or family member (even though the threat may not have been carried out).

Studies have shown that issuing a protective order or arresting a person who commits an act of domestic violence does reduce future incidents of domestic violence. When perpetrators of domestic violence see that the police and court system will treat domestic violence seriously, many persons who commit domestic violence may be deterred from future violence.

But orders of protection are not guarantees of protection or safety. For some individuals with intense anger or rage, no court order will stop their violence, and a court order might even add to the rage. Newspapers periodically carry stories of women murdered by their husband or boyfriend despite numerous arrests and orders of protection. The legal system cannot offer perfect protection, although it can reduce violence.

State Reporting Requirements

Few states have explicit mandatory reporting laws for domestic abuse, and the AMA reports that it is not clear that mandatory reporting would best ensure the safety of competent adult victims or connect them with needed resources. However, virtually all states have some type of statute that requires health care providers to report to law enforcement officials certain injuries that appear to have resulted from a criminal act. The AMA states that the disclosure of a diagnosis of abuse to partners or any third party and reporting to authorities should be done only with the abused woman's knowledge and consent.

In addition, in most areas, there are no government agencies to coordinate case management and put victims in contact with needed services for domestic violence. Thus, health care providers need to be aware of local resources to make appropriate referrals and to advocate for expanded resources.

In any case, health care providers should emphasize that they will remain available to help in the future and should provide the patient with a list of available resources. The health care provider should document the diagnosis, the information conveyed and any pamphlets or materials given to the patient, as well as the patient's decision on whether or not to allow the health care provider to take further action such as notifying the police.

Medical evidence is not required in every judicial undertaking, such as divorce or custody hearings. If court evidence becomes necessary, a well-documented medical record may reduce the time a health care provider is required to spend in judicial proceedings. It may be possible to place the health care provider ''on call" for court, so that he or she need appear only when it is time to testify.

The health care provider may be called to testify about the contents of the record or statements made.

This function is distinct from the use of the health care provider as an expert. The health care provider may be requested to give expert medical testimony and perhaps to give an opinion on whether the explanation given is consistent with the injury. With regard to such testimony, the following guidelines should be followed:

• Insist on pre-trial preparation by the attorney presenting you as a witness
• Know the facts of the case well
• If testifying as an expert witness, propose questions for the attorney to ask
• Brief the attorney on questions to ask the opposing expert
• Listen to the question asked and answer only that question
• If a question is not understood, ask that it be repeated
• Do not volunteer information
• Explain when a one-word answer is not enough
• Calmly correct an attorney who misstates prior testimony

Risk Management

Duty to the Victim

Most health care providers will encounter cases of domestic abuse in their practices. Health care providers must be aware of their obligations in these cases, as well as their potential liability for failing to diagnose and/or report domestic abuse. In general, doing what is medically best or most appropriate is good risk management. If an injured woman is treated by a health care provider who does not inquire about abuse or who accepts an unlikely explanation of the injuries and she then returns to the abusive situation and sustains further injuries, the health care provider could be held liable for those subsequent injuries.

The duty to the victim may arise from the special relationship between health care provider and patient or from the courts' interpretations of reporting laws. The argument would be that other health care providers, under the same circumstances, would have diagnosed inflicted trauma and taken appropriate management steps that would have prevented the subsequent harm. Thus, health care providers must be willing to ask all women patients about abuse, and should know how to diagnose it. Failure to conduct the interview and examination apart from the suspected victim's spouse or partner may interfere with an accurate diagnosis.

Health care providers also should be aware of certain "red flags" that can signal particularly dangerous situations for the woman: stalking behavior by the abuser; substance abuse by the abuser; and threatened suicide by the abuser (increased risk for a murder/suicide). In states that have enacted mandatory reporting statutes, a health care provider's failure to report could give rise to liability, but since reporting laws rarely explicitly give victims such a right to sue, courts must determine whether their state's statutes implicitly contain that right.

Criminal reporting statutes usually are enacted to inform the police of the occurrence of crimes rather than to protect victims of violence. In contrast, child abuse reporting statutes are usually enacted with the clear purpose of protecting abused children, and some courts have allowed abused children to sue health care providers who violate a reporting statute. If a state has a specific domestic violence reporting statute, courts may be more likely to allow a suit against a health care provider who failed to report the abuse.

Duty to Warn

Many states recognize a legal duty that health care providers have toward third parties who might be harmed by their patients. In those states, if a health care provider is aware of a patient's intent to harm a third party, such as the patient's spouse or partner, the health care provider may have a legal duty to breach the patient's confidence and to warn the third party of the impending danger. Health care providers, especially therapists, should know the law where they practice.

Trends in Treatment and Prevention

Living in an abusive relationship takes a tremendous toll on a woman's physical and psychological well-being. As health care providers begin to ask routinely about abuse, they may feel overwhelmed by the prevalence of this problem and by the amount of pain some women experience in their intimate relationships. While maintaining health care provider-patient confidentiality, it is important for health care providers to discuss with supportive colleagues or others how best to respond to such encounters.

All health care providers should begin to respond to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements of recognition, crisis intervention and referral. Some will play a more active role by developing innovative programs, advocating for increased funding for services and for violence prevention programs, and by educating students, community groups and other health care providers. There is much work to be done, but there is a great potential for improving patients' lives, especially when health care providers team up with other professionals and work through local community services.

Several recent trends will improve awareness and outreach in the area of domestic violence. These include hospital-based intervention programs that link with community groups and provide ongoing support and advocacy; community-based training projects to educate health care providers and other health care providers; new residency requirements and additions to medical school curricula that train health care providers to recognize violence and abuse; and the addition of assessment of abuse into existing community outreach programs for women. The AMA is working to assist health care providers in their efforts to reduce violence and the effects of violence in their local communities.

In recent years, state legislatures and courts have been paying increasing attention to domestic violence. Most states have elaborate laws designed to protect individuals from domestic violence by their spouses, other family members, and people with whom the victim may have had a social relationship.

Each state has there own laws regarding the mandatory reporting of domestic violence.

As an example, in California any health practitioner employed in a health facility; clinic; health care provider's office; local or state public health department; or public health department operated clinic or facility is required to make a report if s/he provides medical services for a physical condition to a patient whom s/he knows or reasonably suspects is:

• Suffering from any wound or other physical injury inflicted by his or her own act or inflicted by another where the injury by means of a firearm and/or
• Suffering from any wound or other physical injury, that is the result of assaultive or abusive conduct.

Assaultive or abusive conduct is defined to include 24 criminal offenses, among which are murder, manslaughter, torture, battery, sexual battery, incest, assault with a deadly weapon, rape, spousal rape, and abuse of spouse or cohabitant.

Health practitioner is defined to include practitioners such as a health care provider, surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropracter, licenced nurse, dental hygienist, optometrist, MFCC, MFCC trainee or registered intern, emergency medical technician I or II, paramedic, public health employee who treats minors, coroner, person who performs autopsies, and a religious practitioner who diagnoses, examines or treats children. (This is not a complete definition; see Penal Code 11165.8)

The health practitioner is required to make a report by telephone immediately or as soon as practically possible and send a written report to a local law enforcement agency within two working days.

State Law Online Research Exercise

It is important that healthcare practitioners know the specific laws within the state that that work. WomensLaw.org is a useful site to research state laws pertaining to domestic violence.

WomensLaw.org was founded in February 2000 by a group of lawyers, teachers, activists, and web designers interested in seeing the power of the Internet work for more disadvantaged people and specifically for survivors of domestic violence. The mission of WomensLaw.org is to provide easy-to-understand legal information and resources to women living with or escaping domestic violence.

In this online exercise, complete the following assignment:

• Exercise Objective - Research your specific state laws regarding the definition of domestic violence, mandatory reporting requirements, and other practice related legal statutes.
• Exercise Instructions - Follow these instructions

1. Open another browser window
2. Cut and paste the following URL into your browser: http://www.womenslaw.org/index.htm
3. On the WomensLaw.org site:
• a. Type in the State
• b. Click on Legal Statutes

There may be other links from this web page for additional state information.

Prevention Efforts

Intimate partner violence (IPV) is a serious problem that can have lasting harmful effects on victims and their families, friends, and communities. The goal for IPV prevention is simple-to stop IPV from happening in the first place. However, IPV is a complex problem that demands complex solutions.

Prevention efforts should ultimately reduce risk factors and promote protective factors for IPV. In addition, prevention should address all levels that influence IPV-individual, relational, community, and societal. Effective prevention strategies are necessary to promote awareness about IPV and foster commitment to social change.

Every October, Domestic Violence Awareness Month activities are planned across the country. National, state, and community-based domestic violence prevention and victim service organizations, corporations, health care providers, faith-based groups, other organizations, and CDC will highlight activities that mark the observance with recognition ceremonies, memorial activities, public education campaigns, community outreach events, news conferences and much more.

This section provides links to resources and organizations that address risk and protective factors for IPV through prevention and education activities.

CDC Prevention Program

Intimate partner violence (IPV) is a significant public health problem in the United States. Research indicates that IPV exists on a continuum from episodic violence-a single or occasional occurrence-to battering, which is more frequent and intensive and involves one partner who develops and maintains control over the other.

All forms of IPV, from episodic violence to battering, are preventable. The key to prevention is focusing on first-time perpetration and first-time victimization. Knowledge about the factors that promote IPV is currently lacking. CDC is working to better understand the developmental pathways and social circumstances that lead to this type of violence. In addition, the agency is helping organizations evaluate the effectiveness of existing programs to reduce both victimization and perpetration.

The Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) program seeks to reduce the incidence (i.e., number of new cases) of IPV in funded communities. The program addresses the entire continuum of IPV from episodic violence to battering through a variety of activities.

Federal legislation was passed in 1994 to support the work of Coordinated Community Responses (CCRs) addressing IPV at the local level. US Code Title 42, Chapter 110, Section 10418, Demonstration Grants for Community Initiatives funded nonprofit organizations to sustain IPV intervention and prevention projects, or CCRs, in local communities.

A CCR is an organized effort to prevent and respond to IPV. These efforts can be organized formally (e.g., nonprofit organization) or informally (e.g., group of concerned citizens). CCRs typically involve diverse service sectors (e.g., law enforcement, public health, and faith-based organizations) and populations. Historically, CCRs have focused on providing services to victims, holding batterers accountable and reducing the number of re-assaults. Few have concentrated on stopping IPV from initially occurring, otherwise known as primary prevention.

CDC was given the responsibility of administering the federal funds provided by this legislation. The monies were first used to fund 10 CCR demonstration projects involving case control studies. However, to facilitate "primary" prevention at the community level, CDC began funding the DELTA program in 2002. Nine states were initially funded; five more were added in 2003.

The federal legislation is intended to support community level efforts. CDC funds state-level domestic violence coalitions to provide prevention-focused training, technical assistance and funding to local CCRs. A local nonprofit organization serves as the fiscal agent and receives DELTA funding to support the local CCR's adoption of primary prevention principles and practices. CCRs integrate prevention strategies through increased cooperation and coordination among participating sectors.

Primary prevention is the cornerstone of the DELTA Program. Program activities are guided by a set of prevention principles including:

• Preventing first-time perpetration and first-time victimization;
• Reducing risk factors associated with IPV perpetration or victimization;
• Promoting protective factors that reduce the likelihood of IPV;
• Evidence-based program planning;
• Using behavior and social change theories in prevention program planning and evaluation; and
• Evaluating prevention programs and using results to inform future program plans.

Prevention requires understanding the circumstances and factors that influence violence. CDC uses a four-level, social ecological model to better understand violence and potential strategies for prevention. This model considers the complex interplay between individual, family, community and societal factors, and allows us to address risk and protective factors from multiple domains.

Prevention Strategies

The DELTA program encourages the development of comprehensive prevention strategies through a continuum of activities that address all levels of the social ecology. It is important that these activities are developmentally appropriate and are conducted over several life stages. This approach is more likely to sustain IPV prevention across a lifetime than any single intervention or policy change.

Individual level influences are personal history factors that increase the likelihood of becoming an IPV victim or perpetrator. Examples include attitudes and beliefs that support IPV, isolation, and a family history of violence. Prevention strategies at this level are often designed to promote attitudes, beliefs and behaviors that support intimate partnerships based on mutual respect, equality and trust. Specific approaches may include mentoring and education.

Interpersonal relationship level influences are factors that increase risk due to relationships with peers, intimate partners, and family members. A person's closest social circle - peers, partners and family members - can shape an individual's behavior and range of experience. Prevention strategies at this level may include education and peer programs designed to promote intimate partnerships based on mutual respect, equality, and trust.

Community level influences are factors that increase risk based on individual experiences and relationships with community and social environments such as schools, workplaces, and neighborhoods. Prevention strategies at this level are typically designed to impact the climate, processes and policies in a given system. Social norm and social marketing campaigns are often used to foster community climates that promote intimate partnerships based on mutual respect, equality and trust.

Societal level influences are larger, macro-level factors that influence IPV, such as gender inequality, religious or cultural belief systems, societal norms, and economic or social policies. Prevention strategies at this level typically involve collaborations by multiple partners to promote social norms, policies and laws that support gender equity and foster intimate partnerships based on mutual respect, equality and trust.

Stalking Definition

Stalking is a crime. It is a course of conduct directed at a specific person that would cause a reasonable person to fear death or serious bodily injury. It includes harassment or threatening behavior such as following a person, appearing at a person's home or work, repeated phone calls, repeated written or electronic messages, or vandalism. Many stalking cases involve intimate partners.

Stalking is a crime in all states, however, state anti-stalking laws vary. Many states define stalking as willful, malicious and repeated harassment of a person. Some state laws list examples of unlawful stalking behaviors. Most states require the stalker to engage in a course of conduct, and some states specify the minimum number of incidents required to show that the behavior is not an isolated event.

States definitions of stalking require varying degrees of threats and fear. Some require that the perpetrator make an explicit or credible threat of violence against the victim. Others require that the victim receive an implied threat that would cause a reasonable person fear of bodily injury or death or destruction of property. Also, some definitions include threats against family members.

Stalker Classifications

The National Center for Victims of Crimes categorizes stalkers into 3 general categories. Individual perpetrators may not precisely fit any single stalker category, and often exhibit characteristics associated with more than one category; it is important to remember that these typologies are merely guides.

1. Simple obsessional stalkers are the most common type. They have some prior relationship with the victim, usually an intimate one. These cases most often occur in the context of domestic violence.
2. Love obsessional stalkers have had no existing relationship with the victim. Many of these stalkers target celebrities.
3. Erotomanic stalkers delusionally believe that they are loved by the victim. This is the rarest category of stalkers.

State Laws

A comprehensive list the individual state laws regarding stalking can be found at the following web site sponsored by the National Center for Victims of Crimes: http://www.ncvc.org/src/main.aspx?dbID=DB_State-byState_Statutes117

The following Florida statues are an example of the legal definition of stalking and harassment:

Fla. Stat § 784.048. Stalking; definitions; penalties. Amended 2004.
(1) As used in this section, the term:

(a) "Harass" means to engage in a course of conduct directed at a specific person that causes substantial emotional distress in such person and serves no legitimate purpose.
(b) "Course of conduct" means a pattern of conduct composed of a series of acts over a period of time, however short, evidencing a continuity of purpose. Constitutionally protected activity is not included within the meaning of "course of conduct." Such constitutionally protected activity includes picketing or other organized protests.
(c) "Credible threat" means a threat made with the intent to cause the person who is the target of the threat to reasonably fear for his or her safety. The threat must be against the life of, or a threat to cause bodily injury to, a person.
(d) "Cyberstalk" means to engage in a course of conduct to communicate, or to cause to be communicated, words, images, or language by or through the use of electronic mail or electronic communication, directed at a specific person, causing substantial emotional distress to that person and serving no legitimate purpose.

(2) Any person who willfully, maliciously, and repeatedly follows, harasses, or cyberstalks another person commits the offense of stalking, a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.

(3) Any person who willfully, maliciously, and repeatedly follows, harasses, or cyberstalks another person, and makes a credible threat with the intent to place that person in reasonable fear of death or bodily injury of the person, or the person's child, sibling, spouse, parent, or dependent, commits the offense of aggravated stalking, a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

(4) Any person who, after an injunction for protection against repeat violence, sexual violence, or dating violence pursuant to s. 784.046, or an injunction for protection against domestic violence pursuant to s. 741.30, or after any other court-imposed prohibition of conduct toward the subject person or that person's property, knowingly, willfully, maliciously, and repeatedly follows, harasses, or cyberstalks another person commits the offense of aggravated stalking, a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

(5) Any person who willfully, maliciously, and repeatedly follows, harasses, or cyberstalks a minor under 16 years of age commits the offense of aggravated stalking, a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

(6) Any law enforcement officer may arrest, without a warrant, any person he or she has probable cause to believe has violated the provisions of this section.

(7) Any person who, after having been sentenced for a violation of S. 794.011 or S. 800.04, and prohibited from contacting the victim of the offense under S. 921.244, willfully, maliciously, and repeatedly follows, harasses, or cyberstalks the victim commits the offense of aggravated stalking, a felony of the third degree, punishable as provided in S. 775.082, S. 775.083, or S. 775.084.

(8) The punishment imposed under this section shall run consecutive to any former sentence imposed for a conviction for any offense under S. 794.011 or S. 800.04.

Harrassment

§ 836.10. Written threats to kill or do bodily injury; punishment. 2001.
If any person writes or composes and also sends or procures the sending of any letter or inscribed communication, so written or composed, whether such letter or communication be signed or anonymous, to any person, containing a threat to kill or to do bodily injury to the person to whom such letter or communication is sent, or a threat to kill or do bodily injury to any member the family of the person to whom such letter or communication is sent, the person so writing or composing and so sending or procuring the sending of such letter or communication, shall be guilty of a felony of the second degree, punishable as provided in § 775.082, § 775.083, or § 775.084.

This section contains forms and worksheets that can be used by the health care professional for interviewing and diagnosing of the presence of domestic violence in the patient's life.

Domestic Violence Self-Assessment- This self-assessment worksheet can be used by anyone that the health care professional suspects is the victim of domestic violence. It is a way for the victim to determine for themselves the presence of domestic violence in their lives.

Screening For Domestic Violence In Healthcare Settings- This form contains screening questions and a checklist that the healthcare professional can use to identify general signs and symptoms of relationship violence.⁽³¹⁾

Diagnostic Interviewing When General Signs of Distress Are Detected- This forms contains diagnostic questions and a checklist for identifying specific signs and symptoms of relationship violence.

Diagnostic Interviewing When Specific Signs Are Detected- This form contains suggested questions and comments that the healthcare professional can use in discussing the issue of domestic violence with the victim.

Abuse Assessment Screen- This worksheet should be used to document the specific verbal and physical abuse.

Helping An Adult Who is a Victim of Relationship Violence- This form can be used by the healthcare professional in interviewing, assessing violence and developing a plan for support and safety for adults who are the victim of relationship violence.

Identifying Child Abuse or Neglect: General Signs & Symptoms- With the high incidence of child abuse in cases of domestic violence, it is important that the healthcare professional screen for child abuse. This form will assist in the identification of general signs and symptoms of child abuse.

Identifying Child Abuse or Neglect: Specific Signs & Symptoms- As a follow up to the previous form diagnosing the general signs of child abuse, this form should be used to identify the specific signs of child abuse.

  Name:_____________________

When to screen: Some of the healthcare setting in which a healthcare professional can screen for the signs of domestic violence include: Annual or general exams, adolescent general exams & sports physicals, initial visit with first-time patients, pre-employment physicals (don't note on employer's form), OB visits and premarital exams.

Screening questions: Discussing domestic violence can be a socially uncomfortable so you should consider asking the following kind of questions of the suspected victim violence in private.

Screening for current violence:

Screening for past violence

Course of Action: If screening is positive ask further diagnostic questions

Identifying relationship violence: General Signs and Symptoms

General Signs and Symptoms Warrant Further Assessment:

____ Multiple Emergency Department visits

____ Stress related illness:

____ Drug and alcohol abuse by patient or partner

____ Depression symptoms

____ Anxiety symptoms

____ Suicide attempts

____ Self-injury

____ Post-traumatic stress disorder

____ Divorce or separation

____ Missed appointments or limited access to routine care

____ Lack of independent transportation or finances

Diagnostic Questions: Initially the healthcare provider should identify or rule out violence as a possible source of stress. Some questions include:

Other sources of stress that can be identified include: Major life events (e.g.: move: new job), primary depression or anxiety, or death of friend or relative. There may be acts of violence involved in each of these situations.

Identifying Relationship Violence: Specific Signs and Symptoms

____ Specific Signs of Partner Violence

____ Positive response to screening for family violence.

____ Suspicious injury

____ A person describes their partner as

____ Patient is reluctant to speak or disagree in front of partner

____ A person's partner

____ Accompanies the patient to the exam room and answers all questions

____ Shows angry, threatening or aggressive behavior toward health care professionals

Interviewing: Talk with the person in private. Assure confidentiality: "Our discussion will remain strictly confidential." Ask directly about injuries and abuse:

Screening & Case Finding For Relationship Violence

1. WITHIN THE LAST YEAR, have you been hit, slapped, kicked or otherwise physically hurt by someone? YES NO

2. SINCE YOU'VE BEEN PREGNANT, have you been hit, slapped, kicked or otherwise physically hurt by someone? YES NO

MARK THE AREA OF INJURY ON THE BODY MAP. SCORE EACH INCIDENT ACCORDING TO THE FOLLOWING SCALE:

Name:_____________________ Patient Name:__________________

2. Action: When you observe general signs of distress:

2. Action (When you observe specific signs of abuse or neglect):

Table of Contents-Press "Ctrl+Home"

Table of Contents-Press "Ctrl+Home"

1. National Center for Injury Prevention and Control, Domestic Violence Awareness Month [Website] January 7, 2006 http://www.cdc.gov/ncipc/dvp/dvam.htm
2. National Coalition Against Domestic Violence, President Signs Violence Against Women Act [Website] January 7, 2006 http://www.ncadv.org/
3. Center for Disease Control, CDC Study Documents High Costs and Impact of Intimate Partner Violence October 5, 2005 [Website] December 1, 2005 http://www.cdc.gov/od/oc/media/pressrel/r051025.htm
4. Women's Refuge, Common Myths About Family Violence [Website] January 3, 2006 http://www.womensrefuge.org.nz/understand03.asp
5. Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US); 2000. Publication No. NCJ 181867. Available from: URL: www.ojp.usdoj.gov/nij/pubs-sum/181867.htm
6. National Center for Injury Prevention and Control, Intimate Partner Violence [Website] December 27, 2005. http://www.cdc.gov/ncipc/factsheets/ipvoverview.htm
7. National Center for Injury Prevention and Control, Intimate Partner Violence [Website] December 27, 2005. http://www.cdc.gov/ncipc/factsheets/ipvoverview.htm
8. National Committee for the Prevention of Elder Abuse, Elder Abuse [Website] December 23. 2005. http://www.preventelderabuse.org/elderabuse/elderabuse.html
9. AARP, Then He Hit Me [Website] December 23. 2005. http://www.aarpmagazine.org/family/domestic_violence.html
10. Department of Justice, Rape and Sexual Assault: Reporting to Police and Medical Attention, 1992-2000 [Website] December 30 http://www.ojp.usdoj.gov/bjs/abstract/rsarp00.htm
11. Bureau of Justice Statistics, Crime Characteristics: Violent Crime - Victim/Offender Relationship [Website] December 30, 2005 http://www.ojp.usdoj.gov/bjs/cvict_c.htm
12. National Center for Victims of Crime. Domestic Violence [Website] December 30, 2005. http://www.ncvc.org/ncvc/main.aspx?dbName=DocumentViewer&DocumentID=32347
13. Department of Health and Human Services (DHHS) (US), Administration on Children, Youth, and Families (ACF). Child maltreatment 2003 [online]. Washington (DC): Government Printing Office; 2005. [cited 2005 April 5]. Available from: URL: www.acf.hhs.gov/programs/cb/pubs/cm03/index.htm
14. Department of Health and Human Services (DHHS), Administration on Children, Youth, and Families (ACF). Emerging practices in the prevention of child abuse and neglect. Washington (DC): Government Printing Office; 2003.
15. Fromm S. Total estimated cost of child abuse and neglect in the United States-statistical evidence. Chicago (IL): Prevent Child Abuse America (PCAA); 2001. [cited 2005 Jan 1]. Available from: URL: www.preventchildabuse.org/learn_more/research_docs/cost_analysis.pdf.
16. Mayo Clinic, Domestic violence toward women: Recognize the patterns and seek help [Website] December 30, 2005. http://www.mayoclinic.com/health/domestic-violence/WO00044
17. Mayo Clinic, Domestic violence toward women: Recognize the patterns and seek help [Website] December 30, 2005. http://www.mayoclinic.com/health/domestic-violence/WO00044
18. UCLA Women's Health Center, Domestic Violence Resources [Website] January 7, 2006. http://womenshealth.med.ucla.edu/healthcareproviders/domestic.htm
19. American Medical Association, Diagnostic and Treatment Guidelines On Domestic Violence [Website] January 3, 2006. http://www.ama-assn.org/ama1/pub/upload/mm/386/domesticviolence.pdf
20. American Medical Association, Diagnostic and Treatment Guidelines On Domestic Violence [Website] January 3, 2006. http://www.ama-assn.org/ama1/pub/upload/mm/386/domesticviolence.pdf
21. American Medical Association, Diagnostic and Treatment Guidelines On Domestic Violence [Website] January 3, 2006. http://www.ama-assn.org/ama1/pub/upload/mm/386/domesticviolence.pdf
22. American Medical Association, Diagnostic and Treatment Guidelines On Domestic Violence [Website] January 3, 2006. http://www.ama-assn.org/ama1/pub/upload/mm/386/domesticviolence.pdf
23. WomensLaw.org, What is WomensLaw,org? [Website] January 4, 2006. http://www.womenslaw.org/what_is.htm#whatis
24. Centers for Disease Control, Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA) [Website] December 28 , 2005. http://www.cdc.gov/ncipc/DELTA/default.htm
25. Ambuel, B, & Hamberger, L.K.: Family Peace Project & Community Medicine, Medical College of Wisconsin. 1998