DOMESTIC VIOLENCE
9
Violence Against
Women
Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan, Ninth Edition
Michele Davidson • Marcia London • Patricia Ladewig
Violence Against Women
Endemic in society
Two of the most common forms of violence
are:
Intimate partner violence (IPV)
Sexual assault
Declined 1993 to 2008 (9.4/1000 female ages 12 or
older – 4.3).
Underreported (fewer than half reported to the police).
The cost o violence includes but not limited to: medical
care, mental health services, lost productivity.
Controllers are more likely to be assaultive, sending
partner to emergency
Health care providers can play critical role in
identification and reducing violence, even prevent
homicide.
Role of Healthcare Providers and
Organizations
1985 – Surgeon General identified IPV as
epidemic public health issue
1990 – Joint Commission on Accreditation
of Healthcare Organizations (JCAHO)
mandated the development of case
identification and treatment protocols
Role of Healthcare Providers and
Organizations (cont’d)
 1991 – (revised I 2000) American Nurses
Association (ANA) position statement advocated
education for nurses in identification, prevention
and research on violence.
 Healthy People 2010 ( national health promotion
and disease prevention project) – national priority
 Nurses play a key role in developing and
evaluating innovative health care practices aimed
at reducing violence.
 In 1993, the UN Declaration on the Elimination of
Violence against Women offered the first official
definition of the term “Gender-based Violence”:
“Any act of gender-based violence that results in,
or is likely to result in, physical, sexual or
psychological harm or suffering to women,
including threats of such acts, coercion or arbitrary
deprivations of liberty, whether occurring in public
or in private life.
Historic Factors
Patriarchal societies
Women as property of husbands
“Keep her in line”
Male dominance
Rape – act of aggression against another
man
Domestic Violence
Pattern of coercive behaviors and methods
used to gain and maintain power and
control by one individual over another in an
adult intimate relationship
Among heterosexual couples, estimates
indicate at least 95% of all DV the
perpetrators are men
 Intimate partner violence (IPV) refers to any
behavior within an intimate relationship that causes
physical, psychological or sexual harm to those in
the relationship.
In USA 1 in 4 women will experience DV.
Forms vary but typically described as :
Physical abuse
Sexual abuse
Psychological abuse
Threat to physical or sexual abuse
In JORDAN
 Thirty-four percent of ever-married women age 15-49 have experienced
physical violence at least once since age 15, and 13 percent experienced
physical violence within the 12 months prior to the survey.
 Nine percent of ever-married women age 15-49 report having
experienced sexual violence at least once in their lifetime.
 Overall, 32 percent of ever-married women age 15-49 report ever having
experienced emotional, physical, and/ or sexual violence from their
spouse, and 22 percent report having experienced one or more of these
forms of violence in the past 12 months. •
 Among ever-married women who had experienced spousal violence
(physical or sexual) in the past 12 months, 30 percent reported
experiencing physical injuries (DHS, 2012)
Psychological Abuse
 Emotional abuse: put down, feel bad about self
 Isolation: controlling whom to see and where to go,
jealousy to justify acts
 Obfuscation: denying responsibility, blaming,
distorting the truth
 Using others: use children against her, threat to
take children, use religion to control her
 Male privilege: like servant, rigid male female
roles, making all decisions
 Economic abuse: preventing from getting job,
control her money
 Coercion threats: threats to harm her family, to
commit suicide, to drop charges
 Intimidation: making her afraid by looks and
gestures, display weapons, yelling, stalking her
Physical Abuse
 Pushing
 Shoving and slapping
 Hitting with fist or object
 Kicking
 Choking
 Threatening with gun or knife
Figure 9-1 Homicides of intimate partners by gender of victim, 1993–2007. Source: Catalano, S., Smith, E., Snyder, H., & Rand,
M. (2009). Female victims of violence. Bureau of Justice statistics: Selected findings. Retrieved from
http://bjs.ojp.usdoj.gov/content/pub/pdf/fw.pdf
Sexual Abuse
Forces or tries to force sex
Forced use of objects
Forcing a women to have sex with
someone else
Figure 9-2 The power and control wheel. Source: Adapted from the Domestic Abuse Intervention Project, Duluth,
Minnesota.
Consequences of Abuse
Consequences can be profound
 Physical consequences
 Adverse psychological consequences
 Post-traumatic stress disorder (PTSD),
depression, anti social behavior, anxiety, suicidal
attempts, low self esteem, fear of intimacy.
 Social consequences: restricted access to service,
isolation fro social network, strained relationship
with HCP and employers.
Factors Contributing to Violence
 Childhood experiences: those who witness or
bear abuse more likely to be abusive
 Male dominance in the family: patriarchal
 Marital conflict:
 Unemployment/low socioeconomic status: it
occurs in all SES, however it is more common in
families with low income, unemployment.
 Traditional definitions of masculinity: telling
boys to be tough, not to shy of violence, to hide
feelings.
Common Myths
Battering occurs in small percentage of
population: underreported
Abused women provoke men to beat them:
individually responsible for their act
Alcohol, drug abuse cause battering: shift
responsibility, will not stop violence if
stopped substance
Battered women can easily leave situation:
leaving is easier said than done
Domestic violence – low-income, minority
issue: it occurs among all sectors of
society
Battered women safer when pregnant:
battering may occur first time during
pregnancy or may escalate in intensity
Cycle of Violence
Walker (1984) developed theory
Tension-building phase
Acute battering incident
Tranquil phase (honeymoon period)
Common Characteristics of Batterers
Batterers come from all racial, ethnic, SES,
religious and educational backgrounds
 Insecurity and inferiority
 Powerlessness and helplessness
 Male supremacy
 Emotional immaturity
 Aggression – expression of overwhelming feelings
through violence
 May have been abused
Common Characteristics of Batterers
Nursing Care Management
 Women enter healthcare system in many settings
 May have no visible injuries
 May return to abusive situations
Nursing Assessment and Diagnosis
 Universal screening advocated
 Need comprehensive education, training
 Four basic screening questions




Within last year, have you been hit...?
Since you’ve been pregnant, have you been hit...?
Within last year, has anyone forced you...?
Are you afraid of anyone at home or an ex-partner?
Signs of Abuse
 Neurologic
 Gynecologic
 Obstetric
 Gastrointestinal
 Musculoskeletal
 Psychiatric
 Constitutional
Signs of Abuse (cont’d)
 Trauma
 Other signs
Cues of Abuse
 Hesitation in providing detailed information about injury
 Inappropriate affect
 Defensive injuries
 Delayed reporting of symptoms
 Pattern of injury consistent with abuse
 Inappropriate explanation for injuries
Cues of Abuse (cont’d)
 Vague complaints without accompanying pathology
 Lack of eye contact
 Signs of increased anxiety in presence of possible batterer
Assessment
 Arrange for private place for interview
 Determine sense of pattern of abuse
 Information about strengths support system
 Document extent of injuries
 Use woman’s exact words
 Describe incident
Figure 9-3 Abuse assessment screen. Source: Developed by the Nursing Research Consortium on Violence and
Abuse. Reprinted from the Web site of the Nursing Network on Violence Against Women International
(http://www.nnvawi.org).
Figure 9-3 (continued) Abuse assessment screen. Source: Developed by the Nursing Research Consortium on
Violence and Abuse. Reprinted from the Web site of the Nursing Network on Violence Against Women International
(http://www.nnvawi.org).
Culturally Competent Care
 Lack of ability to seek help outside the family
 Language – barrier to communication
 Inaccurate perceptions of legal system
 Potential threat of deportation
 Religious beliefs conflicting with legal remedies
 Cultural stereotyping
Nursing Diagnoses
 Risk for Powerlessness
 Related to feelings of worthlessness
 Readiness for Enhanced Knowledge
 Information about community resources to assist battered women
 Related to expressed desire to learn about alternatives
Nursing Plan and Implementation
 Reestablish feeling of control
 Supportive counseling, reassurance
 Assist exploration of options, resources
 Allow to make own decisions
 Health promotion education – exit plan
Community-Based Nursing Care
 Inform woman of services available
 Network of community agencies
Needs of Abused Women
 Medical treatment for injuries
 Temporary shelter
 Legal assistance for protection, prosecution of batterer
 Financial assistance
 Job training or employment counseling
 Counseling
Evaluation
 Compassionate, respectful, individualized medical attention
 Recovery from physical effects of physical and sexual abuse
 Information needed to make decisions
 Ability to identify culturally appropriate community resources
available
 All necessary documentation recorded in medical records in
case of prosecution
Sexual Assault
Broad term that refers to a variety of types of unwanted sexual
touching or penetration without consent, from
 Unwanted sexual contact
 Unwanted touching of an intimate part
 Forced anal, oral, or genital penetration
 Rape is on type of sexual assault.
 Rape is: forced sexual intercourse including both
psychological coercion as well as physical force.
 It could be from a stranger, acquaintance, a spouse or
employer.
 Rape is an act of violence expressed sexually
 Remains one of under reported crimes in USA
 1 in 6 above 12 will be victims of attempted or completed
sexual assault or rape in her lifetime.
 Reporting vary by rapist, sequences ( stranger, injury).
Common Myths about Rape
 Only certain types of women are raped: no woman is safe
 Men rape women because that is men’s nature and biological
role
 Women who party hard, drink, and do drugs are setting
themselves up for sexual assault; no blaming the victim for
the crime.
 If a woman just relaxes, it will be over soon
Common Myths about Rape (cont’d)
 Most rapes are interracial: majority are within same
background
 Rapists are easy to spot in crowds: no way o distinguish
them
 Women lie about rape as an act of revenge or guilt: false
rape charges are infrequent
 Fighting back incites rapist to violence: rapists pick up
potential victims they believe may be good targets without a
fight
Characteristics of Perpetrators
 All ethnic, racial, religious, socioeconomic, educational,
professional backgrounds
 Attitudes toward women
 Impulsive, antisocial tendencies
 Male, alcohol and drug use
 Emotionally unsupportive family environment
 Beliefs that support male entitlement
Types of Rape
 Power rape: control or mastery
 Anger rape: assailant used to express feelings of rage
 Sadistic rape: assailant has antisocial personality, delight in
torture. It causes the most injuries
 Stranger rape: often sudden and unexpected
 Acquaintance rape: none stranger, uses deception and trust
 Gang rape: rape is used to reinforce mechanism for member
ship in gangs. Often responding to requests fro group leader,
prove status in the group.
Role of Substances in Sexual Assault
In some case a perpetrator uses alcohol or other drugs to
sedate the victim
 Alcohol most common
 Rohypnol: potent, dissolves easily and oderless
 Gamma hydroxybutyrate (GHB)
 Ketamine
 MDMA (Ecstasy)
 Clonazepam
 Scopolamine
Table 9-2 Indicators of Possible DrugFacilitated Sexual Assault
Rape Trauma Syndrome
 Acute phase
 Outward adjustment phase (denial)
 Reorganization
 Integration and recovery
 Silent reaction
Sexual Assault as Cause of PTSD
 Diagnosis
 Varying degrees of intensity
 Difficult to treat
Physical Care of the Sexual
Assault Survivor
 Primary purpose of care to meet needs of survivor




Evaluate and treat injuries
Conduct prompt examinations
Provide support, crisis intervention, advocacy
Assess for pregnancy risk, sexually transmitted infections (STIs)
Physical Care of the Sexual Assault
Survivor (cont’d)
 Secondary purpose of care
 Collect and preserve legal evidence
 Respect rights of survivor
Tx of women immediately has been as traumatic as the
assault itself “ second rape”
 Violence Against Women Act of 2005
 Sexual assault nurse examiner (SANE)
 Sexual assault response team (SART)
 Tow examples of successful multi disciplinary community
programs that coordinate team of medical, legal and social
service professionals with effective advocacy.
Physical Care of the Sexual Assault
Survivor (cont’d)
 Detailed history essential
 First step in acquiring medical and forensic data
 Can be therapeutic tool: non judgmental / none leading
 Collection of evidence may be traumatic
 Thorough explanation with informed consent
 Chain of evidence
Collecting Evidence of
Sexual Assault
 Purpose




Confirm recent sexual contact
Show force or coercion was used
Identify assailant
Corroborate survivor’s story
 Informed consent
 Complete physical examination for trauma
 Vaginal and rectal examinations
Collecting Evidence of
Sexual Assault (cont’d)
 Clothing
 Swabs of stains and secretions
 Hair and scrapings
 Blood samples
 Urine samples
 Photographs
Nursing Care Management
 Often access healthcare system through emergency
department (ED)
 Nursing assessment
 Create safe, secure environment
 Full mental-status exam
 Scrupulous documentation
Nursing Diagnoses
 Fear
 Related to invasion of personal space
 Secondary to assault
 Powerlessness
 Related to inability to regain sense of control
 Secondary to assault
Nursing Plan and Implementation
 Acute phase
 Create safe environment
 Explain sequence of events
 Outward adjustment phase
 Advocacy, support at level requested
 Assistance to significant others
Table 9-3 Nursing Actions Appropriate to
Phases of Recovery Following Rape
Nursing Plan and Implementation
(cont’d)
 Reorganizational phase




Establish trusting relationship
Assist victim to understand role in assault
Clarify, enhance woman’s feelings
Assist in planning for future
 Integration and recovery
Community-Based Nursing Care
 Reorganization phase
 Health promotion education
 Sexual assault advocacy and information
Table 9-4 General Guidelines for Helping
Victims of Sexual Assault
Evaluation
 Prompt, compassionate, respectful individualized medical
attention
 Recovery from physical effects of sexual assault
 Ability to verbalize recognition that sexual assault is crime of
violence expressed sexually
Evaluation (cont’d)
 Ability to identify culturally appropriate community resources
available
 Ability to make decision about whether to prosecute assailant
 If victim decides to prosecute, all necessary forensic
evidence collected
Prosecution of Assailant
 Crime against the state
 Prosecution is community responsibility
 Victim must report and press charges
 Rape shield laws
Vicarious Trauma
 Gradual internal transformation
 Negatively affect commitment to one’s work
 Reduce sense of accomplishment
 Lead to questioning of personal belief system