Domestic Violence, with a special focus on Human Trafficking

Contents4CME Information and Instructions forClaiming Credit19Treatment Options• Role of the Physician6Historical Perspective• Four Steps for Responding to <strong>Domestic</strong><strong>Violence</strong> in the Health Care Setting• A Team Effort• Definitions• The Governor’s Task Force on <strong>Domestic</strong>and Sexual <strong>Violence</strong>• Establishing a Safety Plan When <strong>Violence</strong>is Identified• The Role of the Emergency Room• Justice System Responses• Continuing Medical EducationRequirement in Florida• Medical Community Responses• Statistics about Victims and Perpetrators• Florida Law on Mandatory Reporting23Endnotes10Characteristics of <strong>Domestic</strong> <strong>Violence</strong>• Evidence of <strong>Domestic</strong> <strong>Violence</strong> inFlorida’s Medical Practices• Characteristics of <strong>Domestic</strong> <strong>Violence</strong>Victims• Characteristics of <strong>Domestic</strong> <strong>Violence</strong>Perpetrators• Characteristics of Trafficked Persons• Other Important Laws and ResourcesAppendix AAppendix BAppendix CAppendix DAppendix EAppendix FAppendix GAppendix HInjury Location ChartA Battered Woman’s Bill of RightsPower and Control WheelAbuser’s PatternsAbusive BehaviorsEquality WheelThe Effects of <strong>Domestic</strong> <strong>Violence</strong>on ChildrenSafety Plan14The Dynamics of <strong>Domestic</strong> <strong>Violence</strong>• Patients’ Reluctance to Disclose <strong>Domestic</strong><strong>Violence</strong>3031CME Post-Test Answer SheetCME Post-Test• Why Doesn’t the Victim Just Leave?• The Use of <strong>Violence</strong> in the Family16Physician Involvement• Screening for <strong>Domestic</strong> <strong>Violence</strong> – Askevery patient• Screening for Human Trafficking• Documentation• Abuse in the Physician’s Personal Lifewww.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking3

the experiences of males who are abused and/or raped. They,along <strong>with</strong> the elderly and children, are included in the generic“she.” Although violence can occur from either partner, themotives of males and females generally are different. Most maleabusers batter their partners as a means of power and control;women who are violent are most often reacting in self-defense [6]or retaliation. <strong>Domestic</strong> violence is also seen in gay and lesbianrelationships.According to the U.S. government, between 14,500 and 17,500people are trafficked into the U.S. annually, <strong>with</strong> over 27 millionpeople enslaved as human trafficking victims around the worldat any given moment. [7] U.S. citizens as well as those who areforeign born are trafficked in the U.S. As human trafficking isa clandestine operation, it is impossible to know the full extentof human trafficking in the U.S. or in Florida. However, manyhave said that Florida is third in the nation as a “destinationstate” for human trafficking victims. [8] About 80 percent ofhuman trafficking victims are women and children;approximately 20 percent are adult males.Approximately 1/3 of injured female rape and physical assaultvictims receive medical treatment: 35.6 percent of the womeninjured during their most recent rape and 30.2 percent of thewomen injured during their most recent physical assault receivedmedical treatment. [9] Most experts agree that statistics aboutdomestic violence and human trafficking in our society are vastlyunderstated.• In 2008, the Florida Department of Law Enforcementreported a total of 113,123 incidents of domestic violence. [16]• In addition to injuries sustained during violent episodes,physical and psychological abuse are linked to other adversephysical consequences including arthritis, chronic neck orback pain, migraine or other frequent headaches,stammering, problems seeing, sexually transmittedinfections, chronic stomach pain and ulcers. [17]• Children who witness domestic violence are more likely toshow behavioral and physical health problems such asanxiety, depression and violence toward peers. They also aremore likely to attempt suicide, abuse drugs and alcohol, runaway from home, engage in teenage prostitution and commitsexual assault crimes. [18]• <strong>Domestic</strong> violence is the leading cause of injury towomen, causing more injuries than muggings, strangerrapes, and car accidents combined.Victims of <strong>Domestic</strong> <strong>Violence</strong> in FloridaYear Total Number of Victims Total Number ofDeaths2008 113,123 1942007 115,150 2142006 115,170 1832005 120,386 1932004 119,772 198<strong>Domestic</strong> violence is one of the largest epidemics the UnitedStates has ever faced.• Nearly one-third of American women (31 percent) reportbeing physically or sexually abused by a husband or boyfriendat some point in their lives. [10]• Seventeen percent of adult pregnant women are battered.Women experiencing abuse in the year prior to and/or duringa recent pregnancy are 40 to 60 percent more likely than nonabusedwomen to have high-blood pressure, vaginal bleeding,severe nausea, kidney or urinary tract infections andhospitalization during pregnancy and are 37 percent morelikely to deliver preterm. [11]• Children born to abused mothers are 17 percent more likelyto be born underweight and more than 30 percent more likelythan other children to require intensive care upon birth. [12]• Leaving the abuser (or taking any act of separation such asobtaining an injunction for protection from the court)significantly increases the danger of being seriously harmed orkilled by the abuser. [13]• 21.7 percent of pregnant teens experience abuse as opposedto 15.9 percent of pregnant adults. [14]• In Florida, there is at least one death at the hands of afamily member every 48 hours. [15]SOURCE: Florida Statistical Analysis Center: FDLE. Crime in Florida, Florida uniformcrime reports, 1992-2008. Tallahassee, FL. http://www.fdle.state.fl.us/Content/getdoc/a324add7-5dd6-4201-9696-93bfd76bc36c/UCR-Home.aspxPrimary Offense 2007 2008 PercentchangeMurder 189 180 -4.8Manslaughter 25 14 -44.0Forcible Rape 979 931 -4.9Forcible Sodomy 353 290 -17.8Forcible fondling 919 744 -19.0Aggravated Assault 19,629 20,462 4.2Aggravated Stalking 234 193 -17.5Simple Assault 89,381 87,303 -2.3Threat/Intimidation 3,041 2,655 -12.7Simple Stalking 400 351 -12.3Total 115,150 113,123 -1.8SOURCE: Florida Statistical Analysis Center: FDLE. Crime in Florida, Florida uniformcrime reports, 1992-2008. Tallahassee, FL. http://www.fdle.state.fl.us/Content/getdoc/4f6a6cd0-6479-4f4f-a5a4-cd260e4119d8/CIF_Annual08.aspx8 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

Florida Law on Mandatory ReportingFlorida law does not require the specific reporting of “domesticviolence” or “human trafficking.” However, Chapter 790.24,Florida Statutes, requires that a physician who is “knowinglytreating any person suffering from a gunshot wound or lifethreateninginjury indicating an act of violence, or receiving arequest for such treatment, shall report the same immediatelyto the sheriff’s department of the county in which saidtreatment is administered or request therefore received.” Thephysician must have had actual knowledge of the violence asopposed to mere suspicion. This means that if a domesticviolence or human trafficking victim has a gunshot or lifethreatening injury as described, physicians must report thatinjury, just as they would for any other person suffering thesame injury. Should the physician knowingly treat such awound, he or she is obligated to report this fact to the sheriff’sdepartment.One of the important things to remember is that it is critical fora physician to screen for and identify domestic violence. If aphysician does not feel comfortable responding in detail to apatient who discloses domestic violence, a staff person shouldbe trained to work <strong>with</strong> that patient, to support her, and toprovide her <strong>with</strong> information about the local domestic violencecenter, where counseling and other services are available.One case was successfully settled by a domesticviolence survivor/plaintiff who sued the hospital aftera physician and the hospital failed to properly screenthe domestic violence victim and, among other things,notice evidence of repeated physical abuse. She alsoalleged that they failed to assess the abusive behaviorof her boyfriend while at the hospital which wouldhave allowed them to see that she was in imminentrisk of danger. After the hospital discharged her, theboyfriend doused her <strong>with</strong> gasoline and set her onfire. She suffered severe injuries, and lived. In short,she alleged that the hospital neither met numeroussafety standards nor did it comply <strong>with</strong> appropriatedomestic violence hospital protocols. [19] Also, in a2009 case, the court determined that a suit couldproceed against a hospital for discharging a husbandwho killed his wife soon after being discharged. Thehospital had potential liability for failing to screen orstabilize the husband in violation of the EmergencyMedical Treatment and Active Labor Act. [20]Even though these cases were not in Florida,physicians must be aware of potential legal problemsassociated <strong>with</strong> the failure to comply <strong>with</strong> a legalobligation to report domestic violence.Regarding the reporting for child, elder or vulnerable personabuse, Chapter 415, Florida Statutes, states that any physician“who knows or has reasonable cause to suspect” that a child orelderly person is abused must report this fact to the Departmentof Children and Families. (The number for reporting is 800-96-ABUSE.) An elderly person is defined as anyone aged 60 orolder. The physician’s name will not be given to the accusedbut may only be used by the Department of Children andFamilies and the State Attorney as they investigate theallegations of abuse. Again, it is possible that a domesticviolence or human trafficking victim will be reported in thesecases, too. For instance, many victims of human trafficking areminors and if a physician suspects that a child under his/hercare is being trafficked, he/she must call that abuse into theHotline.Some states have passed laws that require a physician to reportdomestic violence when he or she becomes aware of it in arelationship. However, mandatory reporting of suspected orconfirmed abuse is strongly opposed by many and can haveunintended consequences, including the following:1. Deterring a woman from confiding in her physician orfrom seeking care.2. Inhibiting providers from screening patients for abuse.3. Impairing a woman’s ability to plan and negotiate a safeexit for herself and her children. [21]4. Threatening the essential tenet of a physician-patientrelationship - confidentiality.For contact information about <strong>Domestic</strong> violence resources in your area, go to www.fmaonline.org/domestic_violence_info.aspxwww.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking9

Characteristicsof domesticviolenceE vi dence of Dome st ic<strong>Violence</strong> in F lori da’sMedical PracticesA woman who is abused suffersemotionally, psychologically, physically andfinancially, which can result in physicaland mental illness and injury. However,most women who are victims of domesticviolence continue to go unrecognized bythe medical profession.Up to 90 percent of battered women do not inform theirphysician of their problem and until recently, few physiciansroutinely asked patients direct questions about abuse in arelationship. This is inconsistent <strong>with</strong> the physician’sresponsibility to provide comprehensive care.Many physicians feel they do not have to be concerned becausethey believe that they do not see victims of domestic violence intheir practices. However, the prevalence of domestic violenceseen in a practice is determined by how many patients are seenand how often the physician asks about the problem. In fact,“the federal Agency for Healthcare Research and Quality(AHRQ) estimates that 2 percent to 4 percent of all womenseen in hospital emergency departments have acute traumaassociated <strong>with</strong> domestic violence and another 10 percent to 12percent of women have a recent history of domestic violence.” [22]The AHRQ further notes that even though most domesticviolence injuries are classified as “superficial,” they estimatethat 73,000 hospitalizations and 1,500 deaths among womenare attributed to domestic violence each year [22] In other words,the percentages of women who are there because of acute orimmediate trauma on account of domestic violence is relativelysmall; however, a much larger percentage of women seekingemergency care have recent histories of domestic violence butare not there because of an immediate domestic violence relatedinjury. For example, a domestic violence victim seekingemergency care due to a stroke is there for treatment of thatcondition, even though she is also a victim of domestic violencewhose health and ability to access care were directly related toabuse. This study also raises the question about whetherdomestic violence is being evaluated correctly as domesticviolence-related injuries are classified as “superficial” eventhough serious injury, and sometimes death, result.Characteristics of <strong>Domestic</strong> <strong>Violence</strong> VictimsVictims of domestic violence are found in every socioeconomiclevel of society and in all educational, racial, ethnic and agegroups. Every survivor is different and the patient you areseeing may not always exhibit these characteristics, althoughthese are the most common.Victims:• Are often fearful of their partners• Are often not allowed access to family, friends, or othersupport networks• Often experience reduced autonomy and/or when theyexercise autonomy, there are negative or abusiveconsequences• Often feel guilty or wonder if they are to blame for theirpartner’s violence• May experience problems sleeping, chronic pain, GIdisorders, nervousness, depression, or signs of Post-Traumatic Stress Disorder (PTSD)10 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

• Are more likely to have more serious injuries (injuries tothe head, neck and torso)• Can often articulate what precipitated specific incidentsor the progression of violence, or• Others (family, friends, etc.) have expressed concern forthe patient’s safety [23]Characteristics of <strong>Domestic</strong> <strong>Violence</strong>PerpetratorsAbusers or perpetrators are also found in all socioeconomiclevels of society, in all educational, racial, ethnic and age groups.Abusers:• Often control access to money, property and other sharedcommodities• Are often notably jealous of friends, family, co-workers,and others• Are often scornful of their partner’s perspective• Can use various forms of status to claim authority,knowledge or power. (e.g., profession, citizenship, age,family background, education, etc.)• Often minimize or explain their behavior, make excuses,or become defensive• Are often vague about violent incidents• May have a documented prior use of violence• Often have offensive wounds (i.e. scratches or bite markswhen injuries are present), or• Use physical force against people or property. [24]Characteristics of Trafficked Persons“As I learned more about trafficking, I realized in retrospect,I saw folks who were trafficked (in my practice) and I didn’tknow to identify them as such. I saw situations <strong>with</strong> ‘mailorder brides’ and their husbands or overbearing employersthat refused to leave the exam room, answering questionsfor the patients. When I learned more about trafficking, itseemed clear that this is another source of adverse lifetimeexperiences that we (physicians) have an obligation to helpin the same way we help child abuse and domestic violencevictims.”David McCollum, MD, Chair of the American Medical Association’sNational Advisory Council on <strong>Violence</strong> and Abuse (March 2005) [25]It is more difficult to construct a similar set of descriptors forthe likely characteristics of a victim of human trafficking. It ismost common that trafficked persons are:• Vulnerable. Victims may have a host of vulnerabilitiesincluding age (either very young or very old), disabilities(developmental, physical, mental), or economic status (mostare desperately poor, in search of work to support theirfamilies).• Isolated by language and culture. Many traffickingvictims do not speak English and do not understandAmerican culture. Traffickers lure their victims into theUnited States <strong>with</strong> promises of good work but then forcethem into prostitution, menial service jobs, sweatshops orfarm work. Victims often have no friends and have noidea what city or country they are in because they aremoved frequently to escape detection.• Distrustful of government and law enforcement. Therisk of being deported leads victims to fear and distrustgovernment and the police e<strong>special</strong>ly when these systemsare corrupt in their country of origin. Also, rarely does thegovernment provide any help or assistance to those inneed. As a coping or survival skill, victims may evendevelop loyalties and positive feelings toward theirtrafficker – a kind of traumatic bonding – and protectthem from authorities.• Unable to see themselves as “victims.” Unlikehomeless people or drug addicts who rely on shelters andpublic assistance, abused individuals do not see themselvesas victims because they have a place to live, food to eat,medical care and what they think is a paying job.Like victims of domestic violence, confidentiality is paramountin human trafficking cases. Victims’ lives and those of theirfamilies are often at great risk if they try to escape theirservitude or aid in criminal investigations of their captors.Therefore, physicians should minimize the number of staffmembers who come in contact <strong>with</strong> the victim. Ensure that allstaff members who have contact <strong>with</strong> the victim, includinginterpreters and advocates, understand the importance ofconfidentiality for the safety of the patient. Physicians alsoshould ensure that interpreters do not know the victim or thetrafficker and do not otherwise have a conflict of interest. [26]Ot her Impor tan tLaws and ResourcesAddress Confidentialit yThe 1998 Florida Legislature passed an address confidentialitylaw. This created a program in the Florida Attorney General’sOffice to grant certain domestic violence victims a confidentialaddress so that they cannot be stalked through public records.The Attorney General’s office forwards all first class mail tothe victim at a new address, thus providing an extra layer ofprotection to victims of abuse.www.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking11

Batterer Intervention ProgramsFlorida law provides for the establishment and certification of“batterer intervention programs” and describes when a courtmust require a domestic violence offender to attend one ofthese 26-week programs. The programs are designed to addressthe violence and “power and control” tactics that a perpetratorhas used toward his intimate partner. They exist throughoutFlorida and are used by the courts <strong>with</strong> varying levels ofconsistency and success. The Department of Children andFamilies administers the batterer intervention program andmore information can be found atwww.dcf.state.fl.us/domesticviolence/bip/index.shtml.Firearms and <strong>Domestic</strong> <strong>Violence</strong>Nationally, and in Florida, firearms are used overwhelminglyin domestic violence homicides. In 2008, 70 percent of thedomestic violence homicides reported by local fatality reviewteams were committed <strong>with</strong> firearms. [28] In 2004, firearmsaccounted for 58 percent of the 68 weapon types used tocommit domestic violence homicides. [29] A national studyfound that women who were threatened or assaulted <strong>with</strong> agun or other weapon were 20 times more likely than otherwomen to be murdered. When a gun was in the house, anabused woman was six times more likely than other abusedwomen to be killed. [30]Cell PhonesIn some locations, battered women may receive free cell phones,many of which are programmed to dial 911 only. These cellphones are donated by individuals and phone companies.Again, local domestic violence centers can provide moreinformation about this service.ChildrenMany of the local domestic violence centers are not fundedadequately to provide critically needed services to children whoneed help. These are some of the most at-risk children in thestate. Services needed include screening and identification ofchild abuse, case management <strong>focus</strong>ing on child safety,individual and group counseling and education aboutalternatives to violence.<strong>Domestic</strong> <strong>Violence</strong> CentersThe Florida Coalition Against <strong>Domestic</strong> <strong>Violence</strong> (FCADV)and the state’s 42 certified domestic violence centers are at theheart of domestic violence services in the State of Florida.These domestic violence centers provide emergency shelter,counseling, case management and a whole range of services todomestic violence survivors and the community. FCADV is thestatewide organization for these centers and works on publicawareness, policy development, creation of standards, provisionof funding, and support for Florida’s domestic violence centers.FCADV operates Florida’s toll-free domestic violence hotline(800-500-1119), maintains a resource library, and developsposters, brochures, safety plans, and other resources. Visit www.fcadv.org.There has been a growing demand for services for victims ofdomestic violence, particularly in the area of outreachcounseling and children’s programs. In fiscal year 2007-2008,Florida’s domestic violence shelters:• Answered 113,323 crisis calls• Provided counseling services to 63,058 individuals• Provided emergency shelter to 14,504 individuals,primarily women and children [27]Both federal and Florida law make it a crime for anyone whohas an injunction for protection against domestic violence topossess a firearm and many courts specifically requirerespondents to surrender firearms when the protection orderis issued. There are some exceptions for on duty lawenforcement (if permitted by their agency) and militarypersonnel.Human Trafficking Referrals and ServicesIn contrast to domestic violence and sexual violence programsand resources, Florida does not have a network of antitraffickingservices or shelters. However, there are someimportant resources available for both reporting humantrafficking and for getting help to victims.At the federal level, the Department of Health and HumanServices has a 24-hour hotline. This national, multi-lingualhotline provides referrals for services in the victim’s area. (888-373-7888 or www.acf.hhs.gov/trafficking). To report humantrafficking to the federal authorities, the U.S. Department ofJustice also has a toll-free number (888-428-7581 voice andTTY). However, it is best to first report human trafficking tolocal law enforcement.Florida has several resources to assist victims of trafficking.These include:• Florida State University, Center for the Advancement ofHuman Rights, 850-644-4550, www.cahr.fsu.edu;• Florida Department of Children and Families, Office ofRefugee Services, 850-922-4143,www.dcf.fl.us/refugee/programs.shtml• Florida Immigrant Advocacy Center, 305-573-1106,Lucha Project, www.fiacfla.org• Florida Freedom Partnership: 866-443-0106,www.floridafreedom.org12 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

The Dynamics of<strong>Domestic</strong><strong>Violence</strong>Patients’ Reluctance toDisclose Dome st ic<strong>Violence</strong>There are many reasons why a patientmay not want to reveal domestic violenceto her physician or other health careproviders. The same is true of victimsof trafficking who may be afraid,ashamed or unaware that they are evenvictims. It should remain their ownpersonal decision to talk about theirproblem whenever they feel comfortable.Victims of domestic violence are competent individuals whounderstand better than anyone else their benefit/risk safetyratio and the practical realities of their own personal situation.Common reasons not to reveal problems include:• Shame and humiliation about what is happening to her.• Feeling that she deserves the abuse.• Fear of retribution if the abuser learns the violence hasbeen disclosed.• Unfamiliarity <strong>with</strong> help that is available in thecommunity to assist her in dealing <strong>with</strong> the problem.• Feeling that a physician is too busy to spend time talkingabout her problems.Why Doesn’t the Victim Just Leave?The most dangerous time for the battered woman is when shefinally decides on separation or divorce. As many as 75 percentof domestic violence calls made to police and 73 percent of theemergency room domestic violence visits occur after separation.Of women killed by their abuser, 70 percent are killed duringthe process of trying to leave their abuser e<strong>special</strong>ly if jealousy ispart of the relationship. It is important to understand thatthere are many reasons why victims of domestic violence andhuman trafficking do not just leave their abusive situations.First, they do leave. It is a myth that abused women stay inabusive relationships. Jacobson and Gottman point out thatabused women actually divorce their abusive husbands at amuch higher divorce rate than the general public. [32] Theyfound that two years after the participants in their study werefirst interviewed, 38 percent of the wives in violentrelationships had left their abusive husbands.Reasons women do not leave include, but are not limited to,the following:1. They may feel they deserve the abuse. Some women feelthe violence directed toward them or their children isdeserved and may represent just punishment. The abuser,<strong>with</strong> verbal abuse, tends to make the victim or victimsbelieve this is true.2. They can’t afford to leave. Financial considerations areone of the primary reasons a woman will remain in arelationship <strong>with</strong> an abuser. She may not have a job thatwill enable her to support herself or her children. Theabuser will often cause a woman to lose her job by makingher miss work (not provide transportation, or batter herwhen she is expected to work). An example of this is whenthe batterer beats his victim in the head and face the daybefore she plans to start work. Needless to say, she will misswork for some days. Housing and transportation are alsomajor problems facing a woman trying to make a decisionto leave a relationship.14 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

3. Fear. These women are often concerned for their ownsafety and the safety of their children, particularly if theyleave the relationship. When a batterer tells the victim thathe is going to kill her, she and others helping her must takethis threat seriously. A woman is at greatest risk of violenceat the time that she decides to leave her batterer. She is fivetimes more likely to be killed after separation or afterdivorce than when she was still in the relationship. Thechance of being murdered increases significantly if jealousyis a problem <strong>with</strong> the abuser.In terms of human trafficking, similar reasons: fear, economicfactors and acceptance of the situation, may keep a traffickingvictim enslaved. In addition, she may be so poor that she mayfeel compelled to stay and work to feed her family in her homecountry, or a woman forced into sex trafficking may feeltremendous shame and be unable to return to her family whobelieved she had legitimate work in the United States. Thesesevere economic and work-related factors are prevalent inhuman trafficking cases, as opposed to domestic violencesituations. Battered immigrant women and human traffickingvictims also share a host of reasons why they might stay in anabusive relationship, including isolation, inability to speakEnglish, lack of community or family support, distrust ofgovernment and law enforcement, and a lack of awareness oftheir rights and the resources available to help them.Abusive BehaviorsAbusers have different ways of expressing their abuse.However, to those who care for victims of domestic abuse,there appears to be a repetitive pattern. Abusive behaviors arenoted in Appendix E.Non-Violent AlternativesThere are methods for dealing <strong>with</strong> problems in a relationshipthat do not involve abuse. For the most part, this involvesconfronting the specific problems that are present in a givenrelationship. It is important to note that “couples counseling”or other joint interventions rarely work to stop violence, and inmany instances can increase the danger to the victim and herchildren. This is because a perpetrator may retaliate against avictim for her honesty in sessions or may continue tointimidate her so she cannot speak openly in session. Theequality wheel depicts qualities of non-violent relationships.(See Appendix F: Equality Wheel.)<strong>Domestic</strong> <strong>Violence</strong> and Its Potential Effecton ChildrenThe effects of domestic violence on children can bedevastating. The physician should be alerted to look fordomestic violence when certain problems occur <strong>with</strong> youngchildren and children through their teens.The Use of <strong>Violence</strong> in the FamilyPower and ControlAn abuser primarily uses domestic violence or the threat ofviolence as a means of maintaining power, control anddomination over his partner. It is also true that domesticviolence usually becomes more severe over time. Abuse will notspontaneously go away. It often begins <strong>with</strong> verbal abuseincluding remarks intended to belittle the victim or make herlose confidence in her actions. It then progresses from badlanguage and shouting to physical and sexual violence. Aperpetrator may be physically abusive only once, but thememory of that violence and the threat to use violence againmay be all that is necessary to keep the victim compliant andfearful. Perpetrators are often obsessively or morbidly jealousand will limit the ability of the woman to contact friends, familyor others in the public, where she might seek help. (SeeAppendix C) Power and Control Wheel. This abuse can alsoinclude financial abuse before and after a divorce when theabuser <strong>with</strong>holds funds from the victim. Even after a divorcewhen the court requires the abuser to make certain payments tothe victim on a timely basis, the abuser can still attempt tocontrol a woman by not making payments on time. This canhave serious consequences when her rent or other bills are dueand she does not have funds to make her payments.www.fmaonline.orgChild abuse and domestic violence frequently existsimultaneously. The most obvious and potentially dangerousrisk for children who live in a home in which there is domesticviolence is that they become direct victims of abuse. In 30 to60 percent of families affected by intimate partner violence,children are also physically abused. [33]<strong>Domestic</strong> <strong>Violence</strong> : In Dating Relationshipsand after DivorceAbuse and tendencies to control often become evident in adating relationship. They are frequently overlooked becausethe victim “loves” her abuser and unrealistically believes orhopes that he will change once they are married and havechildren. A perpetrator’s controlling behavior continuesthroughout the relationship. Even after divorce, many mencontinue to control the lives of their ex-spouses throughlitigation, child custody/visitation manipulation, or throughthird parties. A perpetrator also can continue to exert controlover his ex-spouse by delaying court-ordered payments (childsupport and/or alimony). This will often result in latepayments and large fees and penalties being assessed againsther, ultimately damaging her credit rating. A woman willrespond differently to direct questions about violence in herrelationship depending upon her present stage of response tothe abuse. Therefore, even after divorce, it is still important tocontinue to ask about her safety and about the safety of herchildren during follow up visits.<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking15

Physician InvolvementDome st ic violencecannot bedistinguished by class,race, age, maritalstatus, e ducat ionalstatus or religion, [34]an d i t e xist s wi t hine very group in oursocie t y. <strong>Violence</strong> exists in wealthy,middle class and disadvantaged groups. Itis often advisable to remember thatdomestic violence and human traffickingcan occur among the elderly, immigrants,people <strong>with</strong> disabilities and other groupsthat may not fit the stereotype of avictim. <strong>Violence</strong> perpetrated on the elderlyis an e<strong>special</strong>ly important issue in Floridaas our state continues to have a largepopulation of retired and older residents [35]Universal screening for domestic violencevery likely will also increase the numberof trafficked persons identified in thephysician’s practice.Physicians can also identify domestic violence by simply askinga question or two of each patient. This is the one way thatdomestic violence can be identified before the justice system isinvolved. If this is identified, it may prevent another episode ofbeating of the victim or her children and possibly prevent theirmurder.Screening for <strong>Domestic</strong> <strong>Violence</strong> – Ask everypatientWomen who have been abused often respond positively abouttheir involvement in domestic violence when questioneddirectly. Over one-third of abused women will speak to aphysician or nurse about their abuse if a direct inquiry is made.[36]In four different studies of survivors of abuse, 70 to 81 percentof the patients studied reported that they would like theirphysicians and other health care providers to ask themprivately about intimate partner violence. [37] Asking aboutviolence can improve the outcome for domestic violencesurvivors. Clinical studies have proven the effectiveness of atwo minute screening for early detection of abuse of pregnantwomen. [38] Abuse will usually not be the patient’s primarycomplaint and it is important to ask about domestic violenceeven if the first time you bring it up, she says no or offersexplanations that are inconsistent <strong>with</strong> her injuries. Alsoremember that injuries are likely to be on body parts that arehidden by clothing or on other parts of the body, such as thescalp, that are not easily seen.How should a physician ask the question? Direct questionsthat can be asked include:16 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

• “Are you currently in a relationship <strong>with</strong> someone whothreatens or physically hurts you?”• “Mrs. Smith, when I see people <strong>with</strong> injuries of this type,it is often because someone hit them. Is that whathappened to you?”• “What happens when your spouse loses his temper?”• “Who hit you?” (Ask this if the patient has obviousbruises, e<strong>special</strong>ly facial.)• “Has your partner ever harmed or threatened to harmyou or someone you love?”• “Have you ever been forced to have sex when you did notwant to?”• “Have you ever been afraid for the safety of yourchildren?”You may want to make this kind of statement: “We now knowthat violence in the home is a very common problem and can bevery serious. I routinely ask all of my patients whether they areexperiencing domestic violence because no one should have tolive in fear and because there is help available.”The American College of Obstetricians and Gynecologists hasdone a great deal of work on domestic violence and thephysician’s role, particularly on the issue of universal screening.The following site is e<strong>special</strong>ly helpful to assist <strong>with</strong> screeningquestions:www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585.Additionally, another tool, RADAR [39] is an acronym created bythe Massachusetts Medical Society that many find useful tosystematically screen patients. The acronym stands for:Routine screeningAsk direct questionsDocument your findingsAssess patient safetyReview patient options and referralsAnother option would be to have the following hand-stampedon the chart:DV* Screen Yes__ No ___DV* Referral Yes __No ___(*DV is the abbreviation used for domestic violence.)In Florida, there was concern that if a physician documentedthe domestic violence in a patient’s chart, some insurancecompanies would not pay the insurance benefits because theywould consider the problem a “pre-existing condition.” This wasresolved <strong>with</strong> the passage of a law in Florida which prohibitsthe denial of medical or life insurance coverage for victims ofdomestic violence. [40]Finally, hospitals and other health care facilities shouldconsider adopting a facility-wide tool to help screen fordomestic violence. In 2002, the Agency for HealthcareResearch and Quality (AHRQ) released an evaluation tool thathospitals can use to assess the quality and effectiveness of theirdomestic violence programs. Dr. Jeffrey H. Coben, Director ofthe Center for <strong>Violence</strong> and Injury Control at AlleghenyGeneral Hospital in Pittsburgh, Pennsylvania, and AHRQ’sformer <strong>Domestic</strong> <strong>Violence</strong> Senior Scholar-in-Residence, saidthe tool has been “well received by the research communityand hospital domestic violence programs.” It can bedownloaded at the Agency’s Website at www.ahrq.gov/research/domesticviol. [41] This tool details a range of activitiesthat providers can use to address domestic violence. Thisincludes discreetly placing information about local domesticviolence shelters in the bathroom so the patient has access to it<strong>with</strong>out her abuser knowing that the information has beenprovided.Screening for Human TraffickingIn human trafficking cases, screening for human trafficking isalso important. However, because it is not as prevalent asdomestic violence, the physician should screen when humantrafficking is suspected.A victim of trafficking may look like many of your patients andbe brought in by an existing patient. In one case, a wealthyfamily member brought a young woman they were subjectingto domestic servitude to see their family physician. The wife/mother/trafficker thought her children would be infected bythe trafficking victim’s illness. Traffickers often bring victimsinto emergency rooms, clinics and other health care settings,posing as relatives, caring friends or legitimate employers. Hereare some indicators for both U.S. citizen and foreign-bornvictims of trafficking:• Evidence of being controlled• Evidence of an inability to move or leave job• Bruises or other signs of battering• Fear or depression• Non-English speaking• Recently brought to this country from Eastern Europe,Asia, Latin America, Canada, Africa or India• Lack of passport, immigration or identificationdocumentation [42]www.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking17

According to a recent article posted in JAMA online [43] :“…trafficked persons are often isolated from the public, sothey have little opportunity to see their situation in adifferent light, according to the Campaign to Rescue andRestore Victims of Human Trafficking of the U.S.Department of Health and Human Services.”Trafficking survivors who need health care may have anopportunity to escape their captivity, but only if physicians andothers who treat them are able to recognize and reach out tothem. The agency suggests that clinicians ask the following setof questions of persons who do not seem to be able to move to adifferent location or change jobs, who appear fearful ordepressed, lack identification documents, or who seem reluctantor unable to speak for themselves:• What type of work do you do?• Are you being paid?• Can you leave your job if you want to?• Can you come and go as you please?• Have you or your family been threatened?• What are your working and living conditions like?• Where do you sleep and eat?• Do you have to ask permission to eat/sleep/go to thebathroom?• Are there locks on your doors/windows so you cannotget out?• Has your identification card or documentation beentaken from you?”DocumentationIt is important for the physician to document in the patient’schart evidence of the violence and to be accurate in theirdocumentation. It is important to use direct quotes from thepatient. Appropriate photographs or detailed drawings or asketch of a body are important. (See the Injury Location Chartat Appendix A).This documentation is needed when the justice system becomesinvolved. If the victim seeks an injunction for protectionagainst domestic violence or if the state is going to prosecute aperson accused of domestic violence and the victim cannottestify, accurate medical records describing the abuse are criticalevidence. Medical records are so valuable that many abuserswill accept a plea bargaining arrangement rather than go totrial when they are presented <strong>with</strong> this evidence. Thisinformation also is valuable when legal custody of the childrenis being determined by the court or if the violence escalates tothe point where the abuser is killed by the spouse or one of thechildren. Medical records that substantiate violence may keepthe victim from going to jail should she defend herself and killthe abuser because they validate her claim of self defense. It isimportant to think of the children in these situations who maylose one parent to death only to be separated from the otherparent who may be forced to spend years in jail if convicted of acrime.The same rules regarding documentation apply in cases ofhuman trafficking. The justice system could intervene in thesame ways: prosecuting the offender, providing relief for thevictim <strong>with</strong> an injunction for protection or through a civilaction against the trafficker or <strong>with</strong> child custody and supportissues. Particularly in these cases, medical records would becrucial to corroborating the victim’s story to convict thetrafficker, setting restitution for her and for decidingsentencing.Abuse in the Physician’s Personal LifePhysicians experience domestic violence in their personal livesjust as often as anyone else. They may develop a workingrelationship <strong>with</strong> others in their profession (physicians, nurses,office personnel) in which the physician is “never wrong.”Remember, when you are treating a patient, there may bemultiple ways to treat a given diagnosis. Your education andexperience lead you to choose one of those ways to treat thepatient to the exclusion of the others. This means that you havedecided that the other treatments for that problem are not asgood as the one that you have chosen and that the one youhave chosen is the right treatment. The development of thistype of attitude may lead to an abusive relationship if thebehavior pattern is carried into the physician’s own home. Noone is right all of the time!A physician who reviews the Power and Control Wheel(Appendix C) or the Patterns of Behaviors (Appendices Dand E) and finds some of his/her own personal behaviorrepresented there should consider seeking professional helpto deal <strong>with</strong> this problem.Any health care professional may contact the ProfessionalsResource Network (PRN) at (800) 888-8776.18 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

Treatment OptionsRole of the PhysicianIt is important for the physician tovalidate the patient’s feelings, which mayinclude confusion, worry, anger andsometimes rage. It is critical that thephysician understand that the patient isthe one to make the decision to seek helpaccording to her wishes and needs.Even if the patient does not want to talk about it at a certaintime, there are messages that can be given to help when thetime is appropriate. The patient needs to hear from thephysician that:• You believe her and will listen to her.• She does not deserve to be abused for any reason.• Abuse is a common problem affecting millions ofwomen.• She is not alone.• Help is available from you and your staff, as well as fromother resources in the community. [44]These statements are true for both domestic violence andhuman trafficking victims.Four Steps for Responding to <strong>Domestic</strong><strong>Violence</strong> in the Health Care SettingThe Family <strong>Violence</strong> Prevention Fund’s National ConsensusGuidelines on Identifying and Responding to <strong>Domestic</strong><strong>Violence</strong> in Health Care Settings provides a helpful templatefor physician responses to domestic violence in their practice. [45]1. Provide validation:• Listen non-judgmentally.• “I am concerned for your safety (and the safety of yourchildren).”• “You are not alone and help is available.”• “You don’t deserve the abuse and it is not your fault.”• “Stopping the abuse is the responsibility of your partnernot you.”www.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking19

• The American College of Obstetricians andGynecologists (ACOG) devotes a portion of its web site(www.acog.org/departments/dept_web.cfm?recno=17) tocommunicating specific information about domesticviolence including available services, resources, referralinformation, screening tools, and upcoming educationalopportunities for practitioners. To purchase a copy of the2005 ACOG publication Special Issues in Women’s Health,which includes chapters on Intimate Partner <strong>Violence</strong> and<strong>Domestic</strong> <strong>Violence</strong> and Sexual Assault, as well as AdultManifestations of Childhood Sexual Abuse, visit the ACOGBookstore at www.acog.org/bookstore.• For many years, ACOG has joined local, state, andnational organizations in sponsoring October as <strong>Domestic</strong><strong>Violence</strong> Awareness Month to raise awareness about thispublic health epidemic. Activities often include campaignsencouraging domestic violence awareness in the workplaceand in health care settings, charity shopping days andnational days of recognition. Call your local domesticviolence shelter to find out how you can participate eachOctober.• ACOG and CDC have developed a slide set on intimatepartner violence during pregnancy designed as a trainingtool for clinicians to increase understanding of theimportant role they can play in identifying, preventing, andreducing intimate partner violence. The slide set alsoemphasizes the critical window of opportunity that prenatalcare provides for the screening and referral of pregnantwomen. The slide set is available for download by visitingCDC’s web site:(www.cdc.gov/reproductivehealth/violence/IntimatePartner<strong>Violence</strong>/index.htm)• The American Medical Association, the AMA Alliance,and the Family <strong>Violence</strong> Prevention Fund observed StopAmerica’s <strong>Violence</strong> Everywhere (SAVE) Day and HealthCares About <strong>Domestic</strong> <strong>Violence</strong> Day on Wednesday, Oct. 8,2008. To download free patient education materials,clinical tools and resources by <strong>special</strong>ty, visit www.ama-assn.org/ama/no-index/physician-resources/20012.shtml.• The American Medical Association has devoted entireissues of the Journal of The American Medical Association(JAMA) to the problem of domestic violence. TheDiagnostic and Treatment Guidelines on Family <strong>Violence</strong>,which is a set of protocols for physicians, is also available.Hitting.” Aimed at young children (pre-school through thethird grade), it features simple hand-tracing activities,which teach that hitting others is not appropriate. It maybe obtained from the AMA Alliance at 515 N. State St.,Chicago, Ill. 60610 Phone: (800) 621-8335.Visit www.amaalliance.org/site/epage/40309_625.htm todownload the booklet.• The Florida Medical Association (FMA), the FloridaMedical Association Alliance and their component countysocieties/alliances often work to support domestic violenceprograms at the local level through a variety of efforts suchas organizing fundraisers, adopting abuse shelters, andarranging for volunteer physician services. Contact theFMA, FMA Alliance, or your local county medical societyor alliance if you have ideas to support the domesticviolence programs in your area. Visit www.fmaonline.orgto access a list of all FMA Partners, including countymedical societies and county alliances.• The Family <strong>Violence</strong> Prevention Fund has significantresources to help improve the healthcare response todomestic violence and they have been cited throughoutthis course. They will help train individuals in yourcommunity about better methods to address domesticviolence.Another example of the efforts undertaken by a localcommunity to help resolve domestic violence involves theCrisis Nursery Project of the Hibiscus House, a private, nonprofitshelter for abused children located in Jensen Beach,Florida. This program is designed to help families in a crisissituation receive help before an abusive situation develops,<strong>with</strong>out the involvement of the Florida Department ofChildren and Families. Children can be cared for at theHibiscus House facility for up to 30 days while the familyreceives counseling at Hibiscus House to deal <strong>with</strong> severeproblems <strong>with</strong>in the family. This has been e<strong>special</strong>ly helpfulwhen a woman leaves a violent situation before she has time tomake arrangements for the care and sheltering of her children.They are successful in preventing 98 percent of the familiesfrom being reported for allegations of abuse. Although thisprogram was initially funded by a federal grant, and recentlyby the local community, the program received $193,000 fromthe Florida State Legislature in the 1998 legislative session.Other communities are encouraged to contact this group at(772) 334-9311 for more information about their program.• The American Medical Association Alliance haspublished an activity booklet entitled “Hands Are NOT For22 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

End Notes[1] Fla. Stat. § 741.28 (2008).[2] Family <strong>Violence</strong> Prevention Fund (undated document). National ConsensusGuidelines on Identifying and Responding to <strong>Domestic</strong> <strong>Violence</strong> in Health CareSettings, Family <strong>Violence</strong> Prevention Fund. San Francisco, CA, 2. Found at http://www.endabuse.org/userfiles/file/Consensus.pdf.[3] Definition used by the Freedom Network Training Institute, based on the federalcriminal law definitions of trafficking. See www.freedomnetworkusa.org.[4] Fla. Stat. § 756.031 (2008).[5] U.S. Department of Justice (Feb 2003). Crime Data Brief, Intimate Partner<strong>Violence</strong>, 1993-2001 Washington, DC: U.S. Department of Justice, Bureau of JusticeStatistics. Found at http://www.ojp.usdoj.gov/bjs/abstract/ipv01.htm.[6] Jacobson, N. and Gottman, J. (1998). When Men Batter Women: New Insights IntoEnding Abusive Relationships. New York: Simon and Schuster.[7] See generally, Family <strong>Violence</strong> Prevention Fund. (2005) Turning Pain into Power:Trafficking Survivors’ Perspectives on Early Intervention Strategies. Family <strong>Violence</strong>Prevention Fund. San Francisco, CA. Found at www.endabuse.org.[8] Florida State University Center for the Advancement of Human Rights. (2004)Florida Responds to Human Trafficking. Tallahassee, Florida.[9] Tjaden, P. and Thoennes, N. (Nov. 2000) Full Report of the Prevalence, Incidence,and Consequences of <strong>Violence</strong> Against Women Findings From the National <strong>Violence</strong>Against Women Survey, v.[10] Family <strong>Violence</strong> Prevention Fund. The Facts on Health Care and <strong>Domestic</strong><strong>Violence</strong>, citing Health Concerns Across a Woman’s Lifespan: 1998 Survey of Women’sHealth. The Commonwealth Fund. New York, New York. Found at www.endabuse.org.[11] Family <strong>Violence</strong> Prevention Fund. The Facts on Reproductive Health and <strong>Violence</strong>Against Women, citing Silverman, JG, Decker, MR, Reed, E, Raj, A. Intimate Partner<strong>Violence</strong> Victimization Prior to and During Pregnancy Among Women Residing in 26U.S. States: Associations <strong>with</strong> Maternal and Neonatal Health. American Journal ofObstetrics and Gynecology (2006); 195(1): 140-148. Found at: http://www.endabuse.org/userfiles/file/Maternal_Health/Reproductive_Health_FS.pdf.[12] Ibid.[13] Campbell, J. et al. (July 2003). “Risk Factors for Femicide in AbusiveRelationships: Results From a Multisite Case Control Study.” American Journal ofPublic Health, 3, Vol 93, No.7:1089.[14] Parker, B., McFarlane, J. (1993). “Physical and Emotional Abuse in Pregnancy: AComparison of Adult and Teenage Women,” Nursing Research, Vol. 42. No. 3, 173-177.[15] Florida Department of Law Enforcement (2008) Crime in Florida January –December 2008. Found athttp://www.fdle.state.fl.us/Content/getdoc/a324add7-5dd6-4201-9696-93bfd-76bc36c/UCR-Home.aspx - Click on 2008 “Annual Crime in Florida Report.”[16] Ibid.[17] Ibid. citing Coker, A., Smith, P, Bethea, L, Kind, M., MeKeown, R. (2000). “PhysicalHealth Consequences of Physical and Psychological Intimate Partner <strong>Violence</strong>.”Archives of Family Medicine. 9.[18] Family <strong>Violence</strong> Prevention Fund. The Facts on Health Care and <strong>Domestic</strong><strong>Violence</strong>, op.cit.[19] Brown-Cranstoun, J. “Kringen v. Boslough and Saint Vincent Hospital: A NewTrend for Healthcare Professionals Who Treat Victims of <strong>Domestic</strong> <strong>Violence</strong>?” (Fall2000) J. American Health Lawyers Association, Journal of Health Law. Vol. 33, No.4:629.[20] Bureau of National Affairs “Sixth Circuit Reinstates EMTALA Claims; MurderVictim’s Estate May Pursue Damages” (4-21-09) U.S. Law Week, Vol. 77, No. 40: 1632.[21] American College of Obstetrics and Gynecology (Mar 1998) “Mandatory Reportingof <strong>Domestic</strong> <strong>Violence</strong>.” Committee Opinion. No. 200.[22] Mayes, G. (Posted 08/18/2003) “Are You Safe in Your Home? Medical Screeningfor <strong>Domestic</strong> <strong>Violence</strong> Should Be Routine.” From Medscape Ob/GYN & Women’s Health.Beyond the Examining Room. http://www.medscape.com/viewarticle/459892.[23] Family <strong>Violence</strong> Prevention Fund. National Consensus Guidelines.[24] Ibid.[25] Family <strong>Violence</strong> Prevention Fund. Turning Pain into Power, 2.[26] U.S. Department of Health and Human Services. The Mindset of a HumanTrafficking Victim. Found at http://www.acf.hhs.gov/trafficking/campaign_kits/tool_kit_health/mindset_victim.html.[27] Florida Department of Children and Families. (2008) <strong>Domestic</strong> <strong>Violence</strong> AnnualData Report. Found at http://www.dcf.state.fl.us/domesticviolence/publications/dv0708.pdf.[28] Florida Department of Law Enforcement (2008). Florida <strong>Domestic</strong> <strong>Violence</strong>Review Team Annual Report: 8. Found at http://www.dcf.state.fl.us/domesticviolence/publications/index.shtml.[29] Florida Department of Law Enforcement (2004). Florida <strong>Domestic</strong> <strong>Violence</strong>Review Team Annual Report: 5. Found at http://www.dcf.state.fl.us/domesticviolence/publications/index.shtml.[30] Campbell, J. et al. (not dated). Assessing Risk Factors for Intimate PartnerHomicide, NIJ Journal, 250 Washington, DC: National Institutes of Justice. Found athttp://www.baylor.edu/content/services/document.php/28841.pdf.[31] U.S. Department of State (2007). Trafficking in Persons Report 2007.Washington, DC: U.S. Department of State. Found at http://www.state.gov/g/tip/rls/tiprpt/2007/.[32] Jacobson, N. and Gottman, J. (1998)[33] Edleson J. (1999). “The Overlap Between Child Maltreatment and WomanBattering.” <strong>Violence</strong> Against Women. 5(2). 134-154. Cited in Groves, Betsy McAlister,MSW, LICSW, et al. “Identifying and Responding to <strong>Domestic</strong> <strong>Violence</strong> ConsensusRecommendations for Child and Adolescent Health.” Family <strong>Violence</strong> PreventionFund, 5. Found at http://www.endabuse.org/userfiles/file/HealthCare/pediatric.pdf.[34] Jones, R. F. III. “<strong>Domestic</strong> violence: Let our voices be heard.” Obstetrics andGynecology. 1993. 81: 1-4.[35] See Brandl, B. and Cook-Daniels, L. (Dec. 2002) <strong>Domestic</strong> <strong>Violence</strong> in Later Life.Applied Research Forum, National Online Resource Center on <strong>Violence</strong> AgainstWomen. (VAWNET) http://new.vawnet.org/Assoc_Files_VAWnet/AR_later-life.pdf foran excellent resource on domestic violence and the elderly.[36] McLeen, S. and Anwar, R. “A Study of Battered Women Presenting in anEmergency Department.” American Journal of Public Health. (1989), Vol.79:65- 66.[37] The Facts on Health Care and <strong>Domestic</strong> <strong>Violence</strong> citing Caralis P, Musialowski R.1997. “Women’s Experiences <strong>with</strong> <strong>Domestic</strong> <strong>Violence</strong> and Their Attitudes andExpectations Regarding Medical Care of Abuse Victims.” South Medical Journal.90:1075-1080. McCauley J, Yurk R, Jenckes M, Ford D. 1998. “Inside ‘Pandora’s Box’:Abused Women’s Experiences <strong>with</strong> Clinicians and Health Services.” Archives ofInternal Medicine. 13:549-555. Friedman L, Samet J, Roberts M, Hudlin M, Hans P.1992. “Inquiry About Victimization Experiences: A Survey of Patient Preferences andPhysician Practices.” Archives of Internal Medicine. 152:1186-1190. Rodriguez M,Quiroga SS, Bauer H. 1996. “Breaking the Silence: Battered Women’s Perspectives onMedical Care.” Archives of Family Medicine. 5:153-158.[38] Ibid citing Soeken, K., McFarlane, J., Parker, B. 1998. “The Abuse AssessmentScreen. A Clinical Instrument to Measure Frequency, Severity and Perpetrator AbuseAgainst Women.” Beyond Diagnosis: Intervention Strategies for Battered Women andTheir Children. Thousand Oaks, CA: Sage.[39] Alpert, E. J., et. al. Partner <strong>Violence</strong>: A Guide for Physicians. MassachusettsMedical Society. 1993.[40] Governor’s Task Force on <strong>Domestic</strong> <strong>Violence</strong> (July 1995) The Second Report of theGovernor’s Task Force on <strong>Domestic</strong> <strong>Violence</strong>. Tallahassee, FL: State of Florida: 28.[41] Mayes, G.[42] U.S. Department of Health and Human Services. The Mindset of a HumanTrafficking Victim.[43] Cole, Thomas B. MD, MPH. Modern Slavery a Hidden Crime in the US. (Aug. 3,2005) Medical News and Perspectives American Medical Association. JAMA,.Vol 294,No. 5 541.[44] See generally, Salber, P. and Taliaferro, E (1995) The Physicians Guide to<strong>Domestic</strong> <strong>Violence</strong>. Volcano, CA: Volcano Press.[45] Family <strong>Violence</strong> Prevention Fund. National Consensus Guidelines.[46] McLeen, S. and Anwar, R. (1989) “A Study of Battered Women Presenting in anEmergency Department.” American Journal of Public Health, Vol. 79.[47] See Joint Commission on Accreditation Of Healthcare Organizations (2008). “TheJoint Commission Accreditation Program: Office-based Surgery, Provision of Care,Treatment and Services.” http://www.jointcommission.org/NR/rdonlyres/F0E5686E-248C-4B92-A804-F0FCCA081651/0/OBS_PC.pdf for one example of a JHACO standardon intimate partner violence.[48] Journal of the Florida Medical Association. October 1995, Vol. 82, No. 10.[49] American College of Obstetrics and Gynecology (1995). “Technical Bulletin#209.” Washington, DC: American College of Obstetrics and Gynecology. See alsohttp://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=192 for alisting of ACOG’s extensive efforts to address intimate partner violence.For contact information about <strong>Domestic</strong> violence resources in your area, go to www.fmaonline.org/domestic_violence_info.aspxwww.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking23

Appendix A24 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

A Battered Woman’s Bill of RightsAppendix B• She has the right not to be abused.• She has the right to be angry over past beatings.• She has a right to choose to change the situation.• She has a right to freedom from fear of abuse.• She has a right to request and expect assistance frompolice and social agencies.• She has a right to share her feelings and not to be isolatedfrom others.• She has a right to want a better role model ofcommunication for her and her children.• She has a right to be treated like an adult.• She has a right to leave the battering environment.• She has a right to privacy.• She has a right to express her own thoughts and feelings.• She has a right to develop her individual talents andabilities.• She has a right to legaly prosecute the abuser.• She has the right not to be perfect.Patritia C. Ball and Elizabeth Wyman(Reprinted from Victimology: An International Journal. Vol. 2, No3-4, 1977-78, p. 550Appendix C<strong>Domestic</strong> Abuse InterventionProjectDukuth, MNThe Third Report of theGovernor’s Task Force on<strong>Domestic</strong> and Sexual<strong>Violence</strong> 1997www.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking25

Appendix DAbuser’s PatternsAbuser may exhibit patterns of behaviors that appearroutinely or seem to represent their personal profile. Thesebehaviors are based upon such personal dynamics asbehaviors they observed as a child, past episodes <strong>with</strong>in thecurrent or former relationships and their interpretation ofwhat they stand to lose.• Abuser apologizes• Makes promises/attempts rehabilitation• Blames victim• Denies, rationalizes or minimizes abuse• Gives gifts• “Forgets” incident• No abuse takes place•Tension rises, Becomes prominent• Minor incidents begin• Breakdown of communication• Victim/Family practices “prevent defense,” begins“walking on eggshells”• Any type of abuse occurs (physical/sexual/emotional)Beck Dunn/1997Appendix EAbusive BehaviorsPhysical Abuse• Threatens to hurt or kill• Pushes or shoves• Prevents from leaving at will• Kicks or chokes• Hits, slaps or punches• Throws objects• Locks patner out of the house• Abandons partner in dangerous places• Refuses to help sick, injured or pregnant family members• Subject partner to reckless driving• Rapes or sexually coerces• Threatens <strong>with</strong> a weapon• Abuses pets• Breaks furniture, belongings or personal effectsSexual Abuse• Harasses spouse about imagined affairs• Tells anti-gender jokes• Treats partner as sex object• Is jealous and assumes spouse will have sex <strong>with</strong> anyavailable person• Criticizes sexuality• Insists on unwanted or uncomfortable touching• Withholds sex and affection• Calls spouse sexual names like “whore” or “frigid”• Forces spouse to undress against her will• Publicly shows interest in other partners• Forces unwanted sexual acts• Forces sex when spouse is sick or when it is a danger tohealth• Forces sex for the purpose of hurting partner <strong>with</strong> objectsor weapons• Commits sadistic sexual acts• Tells spouse about affairs• Rapes or sexually coerces26 <strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking www.fmaonline.org

Emotional Abuse• Ignores spouse’s feelings• Ridicules or insults <strong>with</strong> gender characteristics• Ridicules or insults most valued beliefs, religion, race, heritageor class• With holds approval, appreciation or affection as punishment• Continually criticizes, calls names or shouts• Humiliates spouse• Regularly threatens to leave or tells spouse to leave• Punishes or deprives children when angry at spouse• Threatens to kidnap the children if spouse leaves• Manipulates <strong>with</strong> lies and contradictions• Keeps spouse on an emotional roller coaster• Continually finds fault <strong>with</strong> what spouse does and how it isdone• Calls spouse stupid, incapable, or inadequate• Tells the children what a bad parent they have• Tells spouse they are too fat or too thin• Disallows any success or good feelingsSocial Isolation• Doesn’t allow contact <strong>with</strong> family• Doesn’t allow spouse to have friends• If allowed friends, punishes spouse for having them, callsthem names, questions or badgers spouse until relationshipis stopped• Suggests or demands a physical move away from a familiaror safe geographic location• Keeps spouse a prisoner in their own home• Spouse is forced to live on the abuser’s time clock: to bewhere the abuser wants when the abuser wants• Refuses to socialize <strong>with</strong> spouse• Denies spouse access to the carDependency• Keeps wife pregnant• Keeps spouse and the family in debt• If she is employed, causes trouble at spouse’s work; triesto get spouse fired• Keeps partner unemployed or working at a job they dislike• Controls the money or resources; everything is in theabuser’s name• Refuses to work or share money• Makes partner ask for moneyAppendix F<strong>Domestic</strong> Abuse InterventionProjectDukuth, MNThe Third Report of theGovernor’s Task Force on<strong>Domestic</strong> and Sexual<strong>Violence</strong> 1997www.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking27

Safety PlanWhat You Can Do Prior To A Violent Incident• Know how to identify your partner’s/spouse’s level ofviolence so that you can assess danger to yourself and toyour children.• When possible, plan to leave before violence occurs andwhen your partner/spouse is not around.• Go to a safe place. Make arrangements <strong>with</strong> a trustedfriend or someone not known to your partner or spouse. Askthem not to tell anyone.• Notify a neighbor to be alert to strange noises and to callthe police.• If you can, get rid of all weapons in your home if yourpartner/spouse is nearing a violent stage or is in a violentstage of the cycle.• Know your local battered women’s shelter number.• Plan where you will go in an emergency or dangeroussituation. Consider telling your employer not to talk <strong>with</strong> yourpartner/spouse until he or she talks <strong>with</strong> you first, if youbelieve your partner/spouse may come to your workplace.What You Can Do During A Violent Incident• Leave the physical presence of the batterer, if possible.• Leave home; locate your escape items.• Get to a room <strong>with</strong> a lock on the door and/or a telephone.• Call 911 for the police or call your local shelter for batteredwomen.• Have your children call the police.• Scream so your neighbors can hear and will call thepolice.• If you have to leave your children in the home, contact thepolice immediately.• If you leave by car, lock your car doors immediately anddo not unlock the doors until you arrive safely at yourdestination.• Check yourself and children for injuries and go to thehospital, if necessary.• If you cannot leave, protect yourself to the best of yourability.Appendix HWhat Items You Will Need For A Comfortable, Safe Escape• MONEY: Always have some hidden. If you cannot keep itin your own home, put it in a place where you can haveeasy access to it night or day. Plan to have enough moneyfor weekend motel rent, telephone calls, gas and foodexpenses. Be sure you have change and not just currency.• KEYS: Have two extra sets of keys made for your car andyour home; one set for you to put in a safe place and theother to give to a trusted friend.• EXTRA CLOTHING: Prepare a bag <strong>with</strong> extra clothing foryou and your children. Consider the fact that your mighthave to escape in the winter or the summer, so chooseclothing suitable for either season.• IMPORTANT DOCUMENTS: Arrange a plan to gain quickaccess to important documents or copies and other items.These should include the following:-Social Security numbers (his, yours and your children’s)-birth certificates (yours and your children’s)-pay stubs (your husbands and yours)-bank accounts-insurance policies-marriage license-driver’s licenses (yours and a copy of his)-any ownership papers of property-copies of all your monthly bills-valuable jewelry• IMPORTANT TELEPHONE NUMBERS: Include at leastthe following numbers:-local police department or 911-shelter-alternative shelter-victim’s assistance-probation officer-social services-your counselor-his counselorANY OTHER ITEMS OF IMPORTANCE TO YOU AND YOURCHILDRENwww.fmaonline.org<strong>Domestic</strong> <strong>Violence</strong> in Florida: <strong>special</strong> <strong>focus</strong> on human trafficking29