Document Sample
               AND THE ELDERLY


   Domestic violence is perhaps one of the least-publicized crimes in the United States,
but it is far from being uncommon. For various reasons, the exact incidence of domestic
violence is almost impossible to ascertain but there is ample evidence that it is
       Police in the United States spend approximately 1/3 of their working hours
       responding to domestic violence calls.1
       There is some evidence that between 4-15% of all visits by women to emergency
       departments are related in some way to domestic violence.2
       Each year, approximately 1.3 million women and 835,000 men in the United
       States are physically assaulted by an intimate partner.3
       Although domestic violence affects approximately 25% of the population, it has
       been estimated that only 2.5% to 15% of those who have been victimized report
       the problem.4
      Domestic violence is often seen as an issue involving violence by men against
       their partners. However, domestic violence also involves violence by women
       against their male partners and violence against the elderly and children.

    One of the issues in determining the exact incidence of domestic violence has been
one of definitions. Traditionally, domestic violence has been defined as assaults against
women. However, in recent years, it has become clear that domestic violence involves,
and affects teenagers, men, the elderly, and children. It has also become clear that
domestic violence can involve isolated incidents of abuse, persistent patterns of abuse,
psychological abuse, sexual abuse, physical and/or social isolation, deprivation and
neglect, and stalking. In most discussions of domestic violence, the problem often seems
to be defined as physical, sexual, and /or psychological violence against women.
However, domestic violence is far more complex and affects far more people. Although
there is no universally accepted meaning of the term domestic violence, the following
general definition of domestic violence as it applies to all victims will be used here:
Domestic violence is victimization of a person with whom the abuser has or has had an
intimate, romantic, or spousal relationship.5 This module will focus mostly on domestic
violence as it affects women, but the information provided about many of the issues
surrounding domestic violence – why it happens, why abusers abuse, how to detect
domestic violence – essentially applies to all situations of domestic violence.

                                 SCREENING TOOLS
     Detecting domestic violence can be very difficult. As mentioned previously, only a
small percentage of the victims of domestic violence seek help or report their problems,
and there are many reasons for this.6 Women may feel shame or embarrassment, or they
may fear being judged by a healthcare provider. They may fear losing a loved one or the
only stable relationship they have in their lives, or they may fear that they will lose their
children. They may also fear, for various reasons, police involvement, and that reporting
domestic violence will escalate the problem and make it worse. Another reason is that
victims of domestic violence are unfamiliar and afraid of the social services that are
available to them. They may also feel disappointed in the response they receive. As well,
the people around those who are suffering from domestic violence are often unable or
unwilling to report it.7
    But regardless of the roadblocks that prevent women from reporting incidents or
patterns of domestic violence in their lives, it is imperative that nurses be aware of this
problem and educate themselves in the process of screening for domestic violence.
Although there are many reason why health care professionals do not report domestic
violence (inadequate resources, lack of training, perceived lack of time, fear of making
patients uncomfortable, fear of retaliation from the abuser, etc.), making the effort is
important; the discovery rate of domestic violence goes up significantly when nurses are
trained to be sensitive to its possible presence.8 There have been exhaustive attempts
documented in the social science and psychological literature to find the optimum
screening tool, and there are many available. Most should take into account physical
violence, sexual violence, and psychological and/or emotional abuse.9 There are several
that have proven to be valuable. The Women’s Experience with Battering Scale (WABS)
has been shown to be sensitive in detecting domestic violence. While many assessments
for domestic violence focus on recent injuries, this scale identifies more domestic
violence victims than those tools.10 The Women’ Experience with Battering Scale
consists of 10 questions to which the women will agree strongly, agree somewhat, agree a
little, disagree a little, disagree somewhat, or disagree strongly.11 The basis of the
questions is: how does your partner make you feel?

       He makes me feel unsafe even in my own home.
       I feel ashamed of the things he does to me.
       I try not to rock the boat because I am afraid of what he might do.
       I feel like I am programmed to react in a certain way to him.
       I feel like he keeps me prisoner.
       He makes me feel like I have no control over my life, no power, no protection.
       I hide the truth from others because I am afraid not to.
       I feel owned and controlled by him.
       He can scare me without laying a hand on me.
       He has a look that goes straight through me and terrifies me.

   Other valuable tools are the HITS (Hurt, Insult, Threaten, Scream) screen, and the
Women Abuse Screening Tool (WAST).12 The HITS screen is a series of four questions
that asks how often does your partner:

        Physically hurt you
       Insult or talk down to you
       Threaten you with harm
       Scream or curse at you

The WAST screen is a bit more complex and a bit longer.

       In general, how would you describe your relationship?
       Do you and your partner work out arguments with great difficulty, some
        difficulty, or no difficulty?
       Do arguments ever result in you feeling put down or bad about yourself?
       Do arguments ever result in hitting, kicking, or pushing?
       Do you ever feel frightened by what your partner says or does?
       Has your partner ever abused you physically?
       Has your partner ever abused you emotionally?
       Has your partner ever abused you sexually?


   Screening tools can be useful, but there is no single tool that will reliably capture all
instances of domestic violence against women. Also, as mentioned previously, there are
barriers to the self-reporting of domestic violence, and there are also barriers to screening
for domestic violence by health care professionals. But screening can make a difference,
and although having a structured interview tool available is very important, it should be
remembered that the female victim of domestic violence is most often in a very
vulnerable and precarious emotional state. The victims have specific needs that must be
addressed. In particular, female victims of domestic violence prefer that:13

       They are treated with respect and concern.
       They are protected.
       The abuse is documented.
       They are given some control in the process of detection and reporting.
       The response to the violence is immediate, not delayed.
       They are given options.
       There is good follow-up available.

   The interview itself should be conducted in total privacy. This means that all other
persons, children included, are separated from the interviewee. Make sure your nonverbal
behavior communicates concern and compassion. Do not be judgmental. Tell the woman
that what she says is confidential, and express concern for her safety. You can start the
conversation with an open ended question such as, “Do you feel safe at home?”14 Follow
this up with more questions; these can take the form of one of the screens mentioned
earlier, or some less detailed and organized questions. Be sure to respect the woman’s
right to refuse to answer. But regardless of the form that the interview takes, make sure
that the victim understands that her problem is considered by the staff to be serious, the
violence is illegal and wrong, and she is not responsible for it happening.
                       SCREENING: PATTERNS OF INJURY

   Domestic violence is common and has been associated with a range of health
problems such as depression, substance abuse, chronic mental illness, chronic disease,
and overall poor health.15,16 Along with the screening tools and the interview process,
nurses need to be aware of common patterns of injuries that are associated with domestic
violence, especially given the fact that many female victims of domestic violence will not
willingly or openly report it. Several “red flags” can be hints or strong suggestions that
domestic violence is taking place.17,18,19,20

      Is the patient anxious, withdrawn, or depressed, especially when in the presence
       of her partner?
      Does the partner seem overprotective, does he try and dominate the interview and
       answer for the woman? Does he refuse to leave when asked?
      Does the patient appear malnourished?
      Does the patient have unexplained injuries to her breasts, rectum, or genitals?
      Are there unexplained injuries to the face, neck, or throat?
      Does the patient have bilateral, symmetrical injuries?
      Are there unexplained dental injuries?
      Are there obvious fingernail scratches, cigarette burns, or rope marks?
      Does the patient have subconjunctival hemorrhage(s)?
      Does the patient have injuries at multiple sites?
      Are there slap marks with the impression of fingers?
      Are there any bite marks?
      Does the patient have defensive injuries, e.g., to the wrists and/or forearms, or to
       the palms of the hand or the back of the head or neck (these can occur when the
       victim is crouching on the ground to avoid further attacks.


   Risk factors for domestic violence against the elderly include social isolation,
dependency of the elderly person on a caretaker or relative, cognitive or physical
impairments of the elderly person, caregiver stress, and substance abuse by the caregiver.
Awareness of these risk factors is important because in one way or another, they form the
basis of several of the validated screening tools that can be used to detect domestic
violence against the elderly, and they should always be kept in mind when assessing for
the presence of domestic violence against an elderly person. These tools include:

      The Brief Abuse Screen for the Elderly (BASE): This screening tool is comprised
       of five questions: 1. Is the client an older person who has a caregiver? 2. Is the
       client a caregiver of an older person? 3. Do you suspect abuse? 4. What kind of
       abuse do you suspect? 5. If abuse is suspected, how soon do you estimate that
       intervention is needed?
      Caregiver Abuse Screen (CASE) This screening tool is comprised of eight
       questions that are asked of the caregiver: 1. Do you sometimes have trouble
       making the person you are caring for control his/her temper/aggression? 2. Do
       you often feel you are being forced to act out of character or do things you feel
       bad about? 3. Do you find it difficult to manage the temper of the person you are
       caring for? 4. Do you sometimes feel you are forced to be rough with the person
       you are caring for? 5. Do you sometimes feel you feel you can’t do what is really
       necessary or should be done for the person you are caring for? 6. Do you often
       feel you have to reject or ignore the person you are caring for? 7. Do you often
       feel so tired or exhausted that you cannot meet the needs of the person you are
       caring for? 8. Do you often feel you have to yell at the person you are caring for?

      Indicators of Abuse Screen (IOA): The IOA screening tool is longer and more in-
       depth that the BASE or CASE screens. It evaluates the caregiver and the person
       being cared for, and evaluates past history of abuse, history of important
       relationships, financial status of the caregiver and the person being cared for, etc.

Learning Break: There is no national system for system for reporting elder abuse. If
abuse is suspected, call 911 or the local police. If the situation is not urgent, you can call
the National Center on Elder Abuse during the week (1-800-677-1116) or vist their
website ( and you can find the telephone number of the adult
protective services organization in your area.


   There are no universally used, validated screening tools that can be used to detect
domestic violence against children. Screening for domestic violence against children
involves interviewing and examining the child and interviewing the parents or caregivers.
Children should be examined for bruises, burns, or bite marks, and thee should be
examined for patterns. Look for signs and symptoms of malnourishment or poor
nutrition. The parents, caregivers or adults who know the child should be asked: has the
child’s school performance suffered, has the child had sudden changes in behavior, etc.
When interviewing the child take notice of whether or not the child seems apathetic,
depressed, fearful, or withdrawn. Notice the interaction between the child and his/her
parents or caregivers or with adults in general. Is the child fearful? Is the child afraid to
make eye contact? Is there little interaction or eye contact between the child and the

Learning Break: Despite the growing awareness of the problem, of child abuse/domestic
violence against children, study after study has indicated that many healthcare
professionals have not been adequately educated about the issue, do not feel comfortable
in handling suspected cases of domestic violence against children, and do not know what
resources are available.
Learning Break: Child abuse or suspected child abuse can be reported to Childhelp
National Child Abuse Hotline (1-800-4-A-Child)


   The amount of literature that has been published regarding the cause/causes of
domestic violence against women, i.e., why men abuse their partners, is staggering.
Witnessing parental violence during childhood has been shown in many studies to be
strongly associated with influencing battering behavior.21,22 Substance abuse with drugs
or alcohol has also been shown to have a strong correlation with battering behavior.23,24
Perhaps, given the amount of available information, the most useful way to understand
why men abuse their female partners is to focus on three distinct root causes.25

      Psychopathology: It has become clear that male batterers are not a homogenous
       group, and may differ considerably in the severity and type of violence they
       inflict, their alcohol use, level of anger, and level of depression. However,
       researchers have been able to identify distinct subtypes of male batterers.26
       Family-only batterers are men who restrict their violent behavior to the
       immediate family. Their violence is generally less severe, they usually do not
       have severe psychopathology, and they are not in legal trouble outside of the
       home. Dysphoric/borderline batterers may not restrict their violent behavior to
       the family, and their abuse may be sexual and psychological as well as physical.
       There is a chance that they may have serious psychopathology such as borderline
       personality disorder or schizoidal personality characteristics, and drug and alcohol
       abuse may be a problem. Violent/antisocial batterers engage in moderate to
       severe violence, including psychological and sexual abuse. They may have an
       antisocial personality disorder or be psychopaths, often have substance abuse
       problems, and are violent outside of the context of the family. The reasons for the
       behavior of these three subtypes may be genetic (e.g., impulsivity and an irritable
       temperament are both associated with domestic violence and may be inheritable),
       it may be due to early childhood experience and learning (e.g., witnessing violent
       behavior in the home, being abused), or it may be due to peer experiences (e.g.,
       association with deviant peers). Other reasons for violent behavior towards a
       spouse may be attachment problems, a high degree of impulsivity, and poor social
       skills. For example, the dysphoric/borderline batterers may have a pathological
       attachment and dependency on their wives. As well, a batterer may have deficient
       social skills that make solving interpersonal conflicts difficult.
      Cognitive distortions and deficiencies: Some researchers have postulated that
       there is a significant difference in the cognitive processes between violent and
       non-violent men.27 What is of interest is the cognitive content of the violent male,
       how he arrives at that given cognition, and how the cognitive process relate to the
       violent behavior. It has been consistently shown that martially violent men believe
       that marital conflicts are caused by actions of the wife, and this has been called a
       problem with attribution.28 They tend to view their wives with mistrust and
       suspicion and attribute hostile intent to their words and actions, e.g., they believe
       that the wife was trying to publicly embarrass them, make them jealous, or reject
       them. It has also been shown that violent husbands have attitudes that are skewed
       to predispose them to violent behavior towards their female partner. They appear
       to believe more strongly that violence within an intimate relationship is
       acceptable and that traditional roles of male and female behaviors,
       responsibilities, etc., are acceptable and desirable.
       Social skills deficiencies: There is a reasonable amount of evidence that men who
       abuse their female partners have social skills deficiencies, particularly as
       regarding the ability to constructively solve conflict and deal with interpersonal

   Obviously, the reasons why a man becomes violent towards his partner are many and
complex. But it does appear that many men who abuse their female partners have
witnessed violence in their own families while growing up or were subject to it
themselves. It also appears that abusers have poor social skills available to them for
solving conflict30, and drugs and alcohol often play a part. They are suspicious and
mistrustful of their wives and accept violence as a legitimate and acceptable means of
conflict resolution. They often have low self esteem, lack of impulse control and have
antisocial tendencies.31


   The traditional image of domestic violence is the battered wife or female partner.
However, it has become very clear that other populations are vulnerable, including the
elderly, and elder abuse can be considered a form of domestic violence. Domestic
violence/elder abuse is a) a relatively common occurrence, and b) leads to emotional
distress, depression, suicide, and physical harm.
   Elder abuse is a common and under-reported problem. It is defined as “intentional or
neglectful acts by a caregiver or “trusted” individual that lead to, or may lead to harm of a
vulnerable elder.” 32 As with all other forms of domestic violence, the exact incidence of
this form of domestic violence is not known. There is no uniform definition of elder
abuse, there is no uniform state reporting system, and national statistics are not collected.
But there is research indicating that approximately one in ten elderly individuals may be
victims of domestic violence and few of these cases – approximately one in five – are
reported.33 Other studies indicate a frequency of 2% to 10%, that one to two million older
Americans are victims of domestic violence each year, and that the incidence of elder
abuse is increasing.34,35 In addition, surveys of households have shown that the between
12% and 55% of all family caregivers admit that they have abused an elderly person.36
   Domestic violence involving the elderly is in some ways very similar to domestic
violence against women. Most of the abusers are people who are related to the victim.
Physical violence, emotional and psychological abuse, sexual abuse, financial
exploitation, and neglect that lead to harm are the common forms. Also, like domestic
violence against women, there are multiple economic, emotional, psychological, and
social factors that cause/contribute to its development. The elderly may be isolated, less
mobile, and have medical problems that make them dependent on others. Their caretakers
or family members may have been abused themselves or they may be under stress, and it
appears that the abuser is often financially dependent in some way on the elderly victim,
and may abuse drugs or alcohol. At times, if the elderly victim suffers from dementia,
disorientation, or has psychological issues that cause disruptive or disturbing behavior,
this may lead to abuse.

Learning Break: Elderly people who are victims of abuse or neglect are, according to
one survey, have a risk of mortality three times that of the elderly who are not abused,37
and domestic violence involving the elderly often causes serious physical and
psychological harm. However, detection by healthcare personnel – those who should be
most likely to notice abuse – is very low.38


   Although domestic violence involving heterosexual couples/relationships most often
involves assaults by men against women, the use of violence by women against men is
not uncommon. The exact incidence of this problem is of course not known. But what has
been reported is surprising if domestic violence is considered to be – as it has been –
primarily an issue involving assaults against women by men. Several studies have noted
that from 16% to 33% of people identified as the offender/aggressor in situations of
domestic violence were women.39
   There are some similarities in the patterns of female and male violence and abuse
against partners. Women appear to be equally as likely as men to physically assault their
partner and equally as likely as men to use psychological aggression against their
partner.40 Some of the motivations for physical violence appear to be the same for men
and women, as well: one author noted that women use violence because of anger, for the
purposes of retaliation, and occasionally as a way of controlling their partners.41
   However, sexual coercion/violence, stalking, and coercive control are behaviors that
are far more common among men who commit domestic violence, and although women
are just as physically aggressive as men women are far more likely to be injured during
instances of domestic violence.42 Also, women seem to be more likely to use violence as
a tool to gain their partner’s attention or for self-defense.43 Other factors identified as
motivations for women to use violence against a partner are the need to express negative
emotions, jealousy, and the woman’s need to maintain a “tough guise”44 The tough guise
are attitudes and actions that are intended to convey a message that the woman is
independent, dangerous, and not to be threatened or harmed.

Learning Break: The study by Caldwell et al mentioned that women who use the “tough
guise” do so as means of domestic violence, but most of the women who used this tactic
and who used violence for self-defense had been victims of violence by their male
partners. This illustrates one of the difficulties in attaining accurate statistics on domestic
violence of any type. How is domestic violence defined? If someone strikes his/her
partner after being hit, is the second violent act an incident of domestic violence?

   Violence against children is not typically considered “domestic violence,” but the types
of trauma visited against children and the situations in which these traumas occur are
essentially identical to those of domestic violence against women, the elderly and men.
Children can be neglected, physically abused, sexually abused, or simply maltreated.45 In
addition, violence against children is common, it is almost certainly grossly under-
reported, and many health care professionals – quite often the initial point of contact by
the victims with any professional/legal group – are not well trained to detect and/or
manage these cases and are not comfortable doing so.46,47

Learning Break: Detecting, measuring the incidence/prevalence of, and reporting
violence against children is problematic for many of the same reasons these issues are
problematic for domestic violence against women, men, and the elderly. Health care
professionals are poorly trained, there is often no central reporting agency, and there may
be no clear definition of child abuse. But the World Health Organization has defined
child maltreatment as: “All forms of physical and/or emotional mistreatment, sexual
abuse, neglect or negligent treatment or commercial or other exploitation, resulting in
actual or potential harm to the child’s health, survival, development or dignity in the
context of a relationship responsibility, trust, or power.48


    Intervening when a woman reports domestic violence is critical; it can encourage the
woman to leave an abusive relationship and improves their health status.49 The first step
is to make sure, if your patient is indeed a victim of domestic violence, to listen in a
nonjudgmental manner and assure the victim that what has happened to them is both
wrong and illegal. Following that, a useful approach is to use a guide developed by
Alpert.50 The guide is called RADAR and has five steps: Remember, Ask, Document,
Assess, and Review.
    The first two steps have been discussed: Always remember that domestic violence is a
possibility and don’t forget to ask if there is a suspicion that it has occurred.
Documentation is especially important as these cases will eventually enter the legal
system. As well, documenting alerts other healthcare providers to the presence of
domestic violence in the victim’s life, it provides objective data that the injuries sustained
were not accidental, and it helps to determine the actual rate of screening. Be objective in
your documentation, use the woman’s own words and if possible, take photographs.
Following the documentation, make a thorough assessment of the safety of the victim.
The following have been identified as risk factors for significant danger, e.g., possible
homicide, to a female victim of domestic violence:51

      There are weapons in the house.
      The violence has been increasing in frequency and intensity.
      The abuser uses drugs and/or alcohol to excess.
      Weapons have been used to abuse and injure.
      Abuse has resulted burns, broken bones, etc.
      Being forced into sex or into unwanted sex acts.
      Threats to kill.
      Killing of pets.
      Threats of suicide.
      The abuser is violent towards children.
      The abuser is violent outside the home.
      Abuse during pregnancy.

   After the assessment, review the options available to the victim. Encourage her to
make a safety plan.. Make sure she has the appropriate emergency numbers readily
available at home, e.g., police, shelters, emergency rooms, and helpful friends and/or
relatives available. Encourage her to have money, clothing, and important documents pre-
collected and have a clear idea as to where she would go if the abuse reoccurs. Have the
numbers of local organizations involved in helping victims of domestic violence. It is
also helpful to have the telephone numbers and websites of national organizations that
deal with domestic violence. Several helpful ones are:

      The National Coalition Against Domestic Violence. 303-839-
       1852. The website contains a state by state listing of all the national chapters
       along with their 1-800 numbers.
      National Violence Domestic Hotline. 1-800-799-7233
      Family Violence Prevention Fund. 415-252-8900

   Despite abuse, it may be that the woman will decide that she does not want to leave
her partner. It may be that she has developed “learned helplessness,” she may have
internalized her partner’s view of herself as less than worthy, staying with the partner
may be a social norm, she may feel that she hasn’t tried hard enough to make the
relationship work, or she may feels that important needs (financial, social, psychological)
cannot be met without her partner.52 If the woman decides she is going to leave her
partner, make sure she has a plan and is prepared; breaking off a relationship with an
abusive partner can be one of the most dangerous times of the relationship. Encourage
her to:

      Change her phone number.
      Screen calls.
      Avoid being alone.
      Change locks.
      Only meet the partner in a public place.
      Vary the daily routine.
      Get legal help.
      Make sure she has collected all important documents and papers, e.g., social
       security cards, birth certificates, marriage license, leases or deeds, checkbook, and
       any documentation (police reports, photographs, ER records) of the abuse.

  Legal help may involve obtaining a personal protection order. These are especially
useful if the victim has decided to take steps to end the abuse, but does not want to, or
can’t, file criminal charges (e.g., she may perceive the personal protection order as
something that will terminate her relationship with the abuser, and many abused women
do not want to do that). A personal protection order is a court-ordered injunction that
prohibits the abuser from contacting the victim and it is designed to end the abuser’s use
of violence, threats and/or intimidation.53 They are typically issued for an effective
period of 1 to 2 weeks. After that, both parties appear before a judge who decides if the
order should be continued, for how long, or if it should be stopped. If the abuser violates
the condition of the personal protection order, he can be incarcerated. It should be
remembered, however, that the requirements for filing a personal protection order (e.g.,
some states require that the victim pay filing fees, which can be a significant obstacle if
the victim is financially dependent on her abuser) and who can file for one (some states
may not recognize relationships other than traditional male-female marriage) vary from
location to location, and some states require that criminal charges be filed along with the
petition for the personal protection order – and again, this can be a big deterrent for many
   Requirements to report domestic violence vary, and it is not universal throughout the
United States. In addition, the exact definition of domestic violence varies depending on
location. However, The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) does require that all healthcare facilities address the issue of domestic violence
by having policies in place for the identification, evaluation, management, and referral of
domestic violence victims.37 Again, as the laws vary from state to state, it is the duty of
nurse to familiarize herself/himself with her/his hospital’s policy.


    Obviously, prevention of domestic violence is far preferable to treating victims, and it
is generally accepted that treating the batterer is crucial. Battering intervention programs
for male offenders have been in place for many years, and most states mandate
attendance if a man is determined to be abusive. The programs are usually one of two
types: The Duluth model, which is a feminist-based intervention, stresses examination of
sexist attitudes towards woman and the patriarchal nature of society. Proponents of this
approach feel that abusive patterns are learned and can be unlearned. The cognitive
behavioral therapy approach assumes that the men lack the practical social skills to
control their anger and resolve conflicts peacefully, and these skills are taught.
    However, although programs are widely used, there still controversy over whether or
not they work. Some authors have found that these programs do not decrease the
incidence of battering;54,55 it may be that the batterer only stops the abuse while involved
in the program. Other authors have reported success56 but this is the exception.
    Why are these programs unsuccessful? It is known that many men who abuse their
female partners minimize their actions or deny them completely. They feel they have
been forced to attend a program that unfairly punishes them, especially if they feel their
partner initiated the violence or their partner was violent towards them. It is possible that
treatment tailored to the individual, substance abuse counseling, and couples therapy may
improve their effectiveness and decrease recidivism.

    Violence against women is an enormous health care problem, both in the amount
morbidity and suffering it causes as well as the enormous expenditure of monetary,
judicial, and societal resources. Most nurses will, sometime in their career, care for a
woman who has been battered, and they need to be conversant with the process of
screening, interviewing, and intervening in these situations. Nursing diagnoses that may
apply to the situation of domestic violence include violence risk, social isolation,
situational self-esteem disturbance, rape trauma syndrome, family process alteration,
denial, and chronic low self esteem disturbance.
1. Burnett LB, Adler J. Domestic Violence. eMedicine [serial online]. 2006. Available at: Accessed December 22, 2007.
2. Burnett LB, Adler J. Domestic Violence. eMedicine [serial online]. 2006. Available at: Accessed December 22, 2007.
3. Tjaden P, Thoennes N. Full Report of the Prevalence, Incidence, and Consequences of
Intimate Partner Violence Against Women: Findings from the National Violence Against
Women Survey. U.S. Department of Justice, NCJ 183781. 2000. Available at
4. Gracia E. Unreported cases of domestic violence against women: Towards an
epidemiology of social silence, tolerance, and inhibition. Journal of Epidemiology and
Community Health. 2004;58:536-537.
5. Burnett LB, Adler J. Domestic Violence. eMedicine [serial online]. 2006. Available at: Accessed December 22, 2007.
6. Chang JC, Decker M, Moracco KE, Martin SL, Petersen R, Frasier PY. What happens
when health care providers ask about intimate violence? A description of the
consequences from the perspectives of female survivors. Journal of the American
Medical Women’s Association. 2003;58:76-81.
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