# Presentation: 099269

## Domestic Violence

- A Public Health Epidemic
- A Primary Health Issue

## Chapter One 

-    Understanding     Domestic Violence
- Adapted from Improving the Health care to Domestic Violence

## Objectives

- To establish that domestic violence is a health care issue facing patients, families and  practitioners of  all levels.
- To correct misinformation about domestic violence that may block effective responses from health care workers

## Responding

- In order to respond to domestic violence  effectively  health care providers need to have an understanding of ...
- the dynamics of domestic violence
- the causes
- the perpetrators
- the victims
- its impact on health of  victims and their children

**Notes:**

	In recent years we have come to understand that violence in the home has a tremendous impact on the health and future health of the victim and the children involved.
	In order to give an effective response to our patients living in violent relationships we must understand the dynamics and causes of domestic violence.  We must  understand who the perpetrators and the victims are. We must understand the consequences to the health of the victims, the children and the community to make our greatest impact.  

##  I. Definition

- Relationship violence is an escalating
- pattern of abuse where one partner in
- an intimate relationship **controls** the
- other through force, intimidation or
-  threats of violence.

**Notes:**
	Domestic violence  is also often known a woman battering, wife beating, intimate partner violence, relationship violence, spousal abuse, or adult maltreatment syndrome.  We also hear the  derogatory phrase “Indian Loving’’” on and near the reservation.
	Regardless of the term used to identify this serious public health issue, keys to this definition are that it is...

Escalating -Domestic violence rarely gets better and is not a one time event. 
 Control -Force and intimidation, whether physical, threats, financial are used to control the partner over the course of the relationship.
 Intimate  Relationship- Domestic violence is between intimate partners. Whether  dating , engaged, married separated , or divorced, there is some stage of a “romantic’’  relationship between the perpetrator and victim.

## Abuse comes in many forms...

_**Physical**__ _   Kicking, punching, shoving, slapping, pushing, choking, burning and any other acts which may harm a body.

**Notes:**
	Physical Abuse may include spitting, scratching, hitting, restraining, throwing, twisting  punching, choking  burning, use of weapons against the victim. Any other action which is intended to cause harm to a body may be included.

	These events may or may not cause injuries and injuries can be of variable severity.  A seemingly minor physical assertion such as pushing the victim down on the floor could result in a severe injury such as a spinal compression fracture.
 A batterer may abuse his partner with or without outward physical signs. For example abuse during the night time sleeping hours and meals may result in sleep deprivation and poor nutrition. 

## Abuse comes in many forms...

_**Sexual **_   Calling of vulgar names, criticizing body parts or sensuality, forced or pressured sexual acts, including rape.

**Notes:**

	Some perpetrators batter sexually.  This includes a range of conduct  that may include pressured sex, sex when the victim does not it, coerced sex by manipulation and threats ( “I’ll can always find it some where else”), or physically forced sex.  Victims may be coerced or forced to perform sexually acts that they are uncomfortable with  or do not want ( sex with 3rd party, painful sex).   There may include verbal degradation, viewing sexually violent material, sexual acts against her religious beliefs, or comfort level or sex when exhausted or ill.
	Some perpetrators may attack their victims genitals with blows or weapons. Victims may be denied access to contraception  or protection from sexually transmitted disease. 
	Only in the last 3 decades has spousal rape become a crime in this country and victims may be unsure if this behavior is abuse, or spousal rights. Regardless of the specifics the message relayed to the victim  is “ you have no control over your body- you belong to me to do with as I please”.

## Abuse comes in many forms...

_**Psychological **_
- Threats of violence or harm
- Destructive acts against pets, property.

**Notes:**

	Psychological abuse is intended to intimidate the victim.  Threats of harm and violence may be directed at the victim or can be threats of suicide. ( “I’ll kill myself if you leave”.)  Threats may also be directed at the victim's  family and children  (“ Your mother is going to pay”,  “I’ll take the kids and you’ll never see them again.”)   
	Threats including display of weapons, or violence toward others including neighbors  may be used to terrorize the victim.  Perpetrators may coerce the victim into illegal activities then threaten to expose them or threaten accusations to authorities that will result in the children being taken away.

	Destructive acts as attacks against property or pets are not random acts.  Objects that are broken most assuredly belong to the victim, not the perpetrator. The wall that gets struck is near the victims head, not across the room.   She is hiding being the door that gets kicked down. The pet that is killed is her favorite. The message given here is “look what you made me do- you’ll be next.”
	Stalking is also a form of psychological abuse.  The perpetrator may watch the victim from afar and later tell them of what he observed, demonstrating a seeming omnipotence. The intimidation can come by the perpetrator yelling and screaming in the victims face during a fight or driving recklessly when the victim and or children are in the vehicle.

## Abuse comes in many forms...

_**Psychological **_
_**Emotional/ Verbal**_ Assaults against your self-esteem.  “You are so stupid, no one else would want you.”  Name-calling, threats, put-downs. “stupid,  fat, whore” etc.

**Notes:**

	Emotional Abuse  consist mainly of verbal attacks and humiliation. These may include repeated attacks against the victims worth and self esteem, as an individual, a parent, friend ,worker, lover or community member.  These attacks may emphasis vulnerabilities, such as past relationships, past sexual abuse,  HIV status, sexual orientation or  religious beliefs. Emotional abuse may include humiliating her in front of family, friend or strangers, claiming she is crazy and unable to do anything right.

	Sometimes the batterer will play mind games to undercut the victims sense of reality :for example, hiding things then replacing them , asking things to be done than claiming he did not request when she complies.  Emotional abuse may include forcing the victim to do degrading things such a go to the batterers mistress’ home to retrieve her children, cleaning the floor with a tooth brush, eating out of a dog dish.

	Most all couples verbally assault one another during arguments however. In order for a verbal insult to be considered part of domestic violence it must be a part of the coercive pattern of behaviors which the perpetrator uses to threatens to use physical force.

	The presence of emotional abuse may indicate the presence of undisclosed physical force or may indicate that physical force is possible for the future. There is no way to know at present which relationships are likely to progress to physical violence.  Emotional abuse is less physically  visible to the medical provider, but often times causes more damage to the physical and mental health of your patient.

## Abuse comes in many forms...

_**Psychological **_
_**Isolation**_
_**Use of Children **_

**Notes:**

	Perpetrators may try to control the victim through numerous forms of isolation. Isolating tactics often become more overtly abusive over time. including victim's time,  activities and contact with others.  
	At first the perpetrator cuts the victim off from supportive relationships by claims of loving them so much and wanting to be with them all the time.  Guilt may be used “ I guess I love you more than you do me.”, “Why do you need see them when you can be with me?”  These subtle methods are then replaced with statements about interfering family and friends, “dykey” looking friends, and complaints of spending to much time with others including children.  Perpetrators may isolate the victim through acting jealous, accusations of sexual infidelity.  He may claim that family and friends are trying to ruin the relationship  “ they just don’t want us to be happy”
	He may control her by locking her out of the house, taking the car keys, forcing her to quit her job or causing her to get fired.  Over time through incremental isolation the perpetrator increases psychological control over the victim.  Through isolation the batterer prevents discovery about abuse and avoids being held responsible for it. Without outside support and advocacy it becomes more difficult for the victim to avoid psychological control

	Children are used in gaining and maintaining control of the victim in many ways.  They may be engaged as partners in the abuse by be being required to spy on the victim.   If the victim goes out she may be required to always have one child with her, or to leave one child at home in order to ensure that the she will return. If she flees for safety he may manipulate the children saying she left because she is a bad mother and doesn’t love them or that  they are the cause of his anger and abuse or the reason she left. 
	Abuse may involve the children as weapons to control or punish the adult victim. There may be physical or sexual abuse of the children.  The children may be forced to watch the abuse of the victim or be forced to participate in the abuse. Children may be drawn into physical assaults in attempt to protect the victim or when the victim holding an infant and being thrown against a wall. He may threaten kidnapping the children. 
	The perpetrator may refuse to pay child support.  Visitations with children may be used as opportunities to question about mothers activities. There may be threats of custody fights. If the perpetrator is a tribal member on the particular reservation while the victim is from another.  She may fear loosing the children in his tribal court.

## Abuse comes in many forms...

_**Economic **_ Controlling money and resources, using financial contribution as power, making all financial decisions.

**Notes:**

	Perpetrators may control their victims by controlling access to family resources such as transportation, time, food, health care, shelter, money and insurance.  This can occur if either or both are the primary financial contributors.  The perpetrator may control the check book and the money flow, give allowances out for groceries, and bills.  He may refuse to work and insist that she support the family or threaten to quit work and not provide child support in the event she attempts to leave. He may control how the finances are spent spending money on items he desires while neglecting basic needs.  He may refuse to allow his partner to work outside the home , prohibiting financial independence on her part and maintaining dependence on himself. 

	In all instances he is the one who make the decisions about how money is spent, and earned. These tactics are used regardless of financial status.

## Abuse comes in many forms

- The use of physical and sexual force  give power to the psychological  abusive acts

**Notes:**

	Psychological battering becomes an effective weapon in controlling victims because they know from experience that the batterer will back up his threats with actual physical harm.
	At times the physical violence only need occur once.  Afterward only threats of recurrence are needed to maintain control over the victim.  References to past violent relationships might even be used to intimidate a new partner. “ You acting like Susie – You know what happened to her”.  Psychological control through intermittent use of physical abuse  is typical of domestic violence. Physical abuse, threats of harm, and isolation tactics are interwoven with loving gestures (gifts, flowers,  and promises that it will never happen again)
	 These occasional indulgences are also described by Amnesty International in reference to hostages  and POWs as a method of coercion used in torture. These tactics provides a positive manipulation. “See what a nice guy I am if you do what I want.”  The message is always there that if the loving gesture is not appreciated enough the threats and danger will escalate again and the batterer will use whatever tactic is needed to obtain compliance and submission.  This same tactic is used against hostages or prisoners of war.

## Abuse comes in many forms

-        Mutual Battering
- 		Rare- motivation of the victim
-          is self defense

**Notes:**

	Mutually verbally abusive language is common in relationships.  Studies show that those who are physically abusive are more verbally abusive than those persons who are nonviolent.  Physically abuse persons also are shown to be more verbally abusive than either partner in a stressed or non-stressed relationship.
	Perpetrators may report defensive actions of the victim as battering. Careful assessment when physical injuries have occurred to both parties will show that one person was the aggressor and the other attempting to defend herself or her children. These are most are often acts of resistance  to physical assaults on the part of the victim.
	Research on heterosexual couples indicates that a women’s motivation in use of physical force is self defense. While men use it for power and to gain control.  Mutual combat among gay and lesbian couple is also rare. There is usually a primary aggressor creating the atmosphere of  fear and intimidation for the partner. 

- Physical violence typically starts when the couple has become more seriously involved:
- 	        engaged
-             living together
-             “going steady”
-             after marriage
- 		   pregnancy
-             after birth of a child

**Notes:**

	Though physical abuse does typically start after there is more serious involvement, or a demonstration of “ownership”  in the relationship ( engagement, pregnancy, marriage etc. )  there is no strict linear pattern to abusive relationships. For some the abuse escalates from verbal, to minor assaults, to more severe assaults. For others the physical assaults will stabilize or decrease as the perpetrator changes to tactics that may be more fruitful. In this instance physical abuse may be used  early on, thus laying  down the “ pecking order” in the relationship.  Many women  will report that they have only been assaulted physically one time by their abusive partner but verbal threats of repeating the incident are used to maintain control.  

## II. Why does this happen? 

**	****Abusive relationships are based on the mistaken belief that one person has the right to **_***control***_** another. **
**	****The relationship is based on the exercise of **_***power to gain and maintain control.***_

**Notes:**

	The purpose of these actions is for the batterer to assure his security in the relationship and position of dominance. to maintain control and compliance of the partner. 
	Similar tactic are used in other life situations such as gaining compliance form another country in time of war through intimidation, economic embargos and threats of and physical assaults.  Some persons use these tactics as well to gain submissive behavior from pets. In days of slavery physical  punishment was used as well to gain submission and compliance from those considered property. Similarly victims of abuse are considered possessions or property to be dealt with as felt indicated by the perpetrator. 

## Causes of Domestic Violence

- Domestic Violence is...
- ...a learned behavior. Batterers learn from observations of other people, including family, friends and society
-    Violent and coercive tactics are used because they often work and the batterer too often is not held responsible

**Notes:**

	Batterers learn tactics of controlling from family, friends, society and media.  These tactics are used because they work.  Even when we are children we learn that if  “ I hit Billy he will give me the toy he has”.  If I continue to get away with it , or the behavior is reinforced then it continues.  In domestic violence it is the same. We fear pain so we give in.  Batterers are not held responsible, excuses are made.  ( “he was drunk”, “she asked for it” , “It’s family matters- none of my business”)  Abusive  behavior is reinforced.

	Like some other forms of aggression domestic violence is not cased by genetics or illness. People are not born to be perpetrators but over time with observation of individuals and institutions. This behavior includes the perpetrator’s own internal rules and regulations about when, where, how and against whom and by whom domestic violence is to be used . These beliefs are learned form direct observation. They are then reinforced through peer support and not being held responsible. The batterers behavior may even be reinforced by  bystanders, family  and peers who fail to intervene. The batterer may justify his actions  to himself because of socially sanctioned belief that men have the right to control women.

	Domestic violence has traditionally been reinforced  by societies major institutions including family, social ,legal religious, educational  entertainment , health, medical   and media.   Many major religions support domestic violence by stating that a woman should submit to the will of her husband,  and that the family should stay together at all costs.  Legal systems don’t hold perpetrators responsible with laws, fines, sentences.  Medical and mental health systems ask what the victim did to provoke the abuse and why doesn’t she just leave.

## II. Causes of Domestic Violence

- Domestic Violence is a gender specific behavior

**Notes:**

	 Domestic violence is a gender specific behavior in that most occurs male batterer to female victim.  This behavior has been historically and socially constructed. Men are socialized to control and  to be physically strong in order to maintain dominance.  Male violence against women in intimate relationships is a social problem which has been condoned and supported by the customs and traditions of  a particular society.
	Women who use physical force typically use less force. Violence occurs at a lesser frequency and severity as men’s. The purpose of a woman's physical force is for self defense.   For mean it is for power and control.  Men who are killed by their abused spouse are more severely violent rot both the women and children in the home.
	 Native societies did not traditionally condone these behaviors.  Women in pre reservation society held very high honor in many  spectrums of life. Traditional creation stories  show woman created as the companion of man, not a  subordinate.  Men and women existed as equals.  Christian traditions and beliefs in brought these traditions to Native American peoples  With example and colonization oppression these behaviors have now been incorporated into Native American homes to varying degrees.  

## Demographics

- Relationship violence occurs in **every** race, religion, ethnic group and social class.
- Relationship violence occurs in **both** heterosexual and homosexual relationships.
- Relationship Violence occurs male to female(95%) and female to male (5%)

**Notes:**

	Domestic violence occurs in every social, religious, cultural and ethnic group.  Prevalence varies in each category from rare to over 99% .  Prevalence  and severity is  influenced  competitiveness between men and women,  tolerance of violence  and presence of support networks.

	In same sex relationships patterns of development of  the dominant roll are different than heterosexual relationships. Gay males may have difficulty identifying as victims   because it is considered “unmanly”. Domestic violence in gay relationships may be condoned by some because “that’s the way men are”   Lesbians however may deny that domestic violence exist in the community because “women are not like that”.  Same sex violence  is in need of more studies  to compare it with heterosexual domestic violence.  There to date no such studies have been done

	In all  observed  societies wife beating is more common than husband beating. Factors that influence prevalence include consequences, acceptability, polarization for male and female roles, value of women’s contribution to family and society.  Domestic Violence female to male , is usually much less severe and less frequent in occurrence.

## Cultures With Higher Incidence

- Patriarchal
- Patrilineal
- “Women’s work” is undervalued
- Genders roles are very polarized
- Arranged marriages

**Notes:**

	Cultures where domestic violence is more prevalent have a patricidal tradition in which a male member of the family of clan is consider the leader.  They are also typically patrilineal where in a marriage the woman will go to live with the mans family or to his village or town. Inheritance is typically passed down through the male heirs as well.   In these situations a woman is less likely to have support of the female members of the husbands family and her own family may be a distance away. Making support difficult.
	In cultures were ‘women’s work” is undervalues or female traits are considered less desirable.   “ that woman's work”  You run like a girl”, Wear in a skirt would be a shameful punishment in our American culture for a male. All things that express the favor of the male sex and a degradation of the female sex.

In culture where genders are very polarized and gender roles are very defined ( Women cook and care for children, men hunt ) crossing the line is unacceptable. I our American society these roles have been very polarized until recent generations.  Crossing over roles was considered abnormal before .

In culture were marriages are arranged violence is more prevalent, In these cultures the woman is frequently given over for a dowry which is essentially a payment for the bride. When a woman can chose for here self her partner, violence is less prevalent. 

## In Indian Country...

- In Indian  Country domestic violence also varies in prevalence with tribe to tribe.
- As with other Communities incidence  and severity varies from family to family

**Notes:**

	In one unpublished review of 100 charts of women age 15 to 99 from one IHS clinic - 59 % had documentation of domestic violence in their medical charts  at some point in their life.  In a recent study release by the US Department of Justice, Native American women were the most likely of any ethnic group to report rape, physical assault or stalking during their lifetime.
	History of violence during colonization, and boarding school times likely plays a major role in the level and prevalence of violence occurring form one community to another as well as within extended family groups. In the U.S, families come from many, often mixed cultural back grounds. Domestic violence in extended families varies in acceptability and prevalence  influenced by these extensively variable roots.  These historical influences on Native peoples have likely influenced the  variability in domestic violence acceptability, severity and prevalence from location to location

## Domestic Violence Vs Illness Based Violence

- Illness
- Organic brain disease
- Target is whoever is present
- Changes in speech, gait,
- May be psychosis
- Progression with disease

- Domestic Violence
- Learned
- Target intimate partner
- Coercive

**Notes:**

	A small percentage of  violence against adult intimates is illness based.  These is caused by progressive organic brain disease such as Alzheimer's, Huntington's Chorea or psychosis.  In organic disease the imitate partner may be struck at , however the victim is whoever is present when the short circuit occurs.  This may be friend, family, physician or stranger.  (“I attacked her because she is a  CIA agent sent to spy on me”) It is not coercive.  Illness based violence is not coercive as is domestic violence but is associated with disease progression. Domestic violence would be unlikely to start after a 20 year marriage but illness based violence would with progression of disease. Other symptoms and signs of illness should manifest in time if not already witnessed.

## Domestic Violence and Substance Abuse

- Domestic Violence Is not Caused by Alcohol or other drugs

**Notes:**

	Alcohol and drugs are often used an excuse or blames for causing domestic violence.  Many people use and abuse alcohol and other drugs and do not batter their partners. Many batterers also do not use alcohol or drugs. Many women have disclosed that violence in their relationship was in fact worse with sobriety of their batterer.
	Substance abuse may release inhibition that “allow’ an individual permission to do things they would not do otherwise. Some drugs such as steroids, PCP. Crank  or cocaine  may chemically react with the brain to cause violent or paranoid behavior. Further research is needed however to explore this cause and effect.
	The presence of alcohol or drugs is highly relevant in the lethality assessment. The use of substances may increase the potential  lethality of domestic violence  and should be addressed in safety planning for the victim and children.

## Dispelling Myths

- Domestic Violence is _not_ caused by anger
- Domestic Violence is _not_ caused by Stress
- Domestic Violence is _not_ causes by the victims behavior or the relationship

**Notes:**

	Domestic Violence is not caused by anger. It is a pattern of behaviors and many of these abusive  episodes occur in a calm manner. Some displays of anger and emotion are for the purpose of intimidation and these can be quickly changed  when needed such as upon the arrival of the police. Studies have shown that some abusers heart rate will actually go down during a conflict  suggesting a calm preparation of a seemingly out of control, angry response.  
The individual is responsible for how they express emotions including anger.

	People respond to stress in different ways. All lives are filled with stress. People learn to respond to stress according to the strategies they have witnesses.  Individuals are responsible for the choices they make in responding to stress. Many episodes of domestic violence occur when the perpetrator is not stressed. Again domestic violence is a pattern of events  and specific stressor are not meaningful to excuse it in the long term.

	All people have conflict in relationships and dislike some behavior of their partner.  Most do not resorting to violence as a response.  Focusing on the behavior of the victim or problems in the relationship as  reasons for the violence removes the perpetrators responsibility and gives support to the perpetrators minimization and denial of the abuse. This blames the victim and justifies the conduct further reinforcing the behavior of the perpetrator.
	Many batterers bring the pattern of control, and coercion into their adult relationships and repeat it in their intimate relationships regardless of the personality differences of intimate partners. This supports that  the behavior is not caused by the relationship. There is also not personality profile which for battered women which also supports that while violence takes place in the relationship ,it is not caused by the relationship. Studies show that no behavior of the victim will alter the behavior of the perpetrator suggesting that the victims behavior is not  a factor in determining abusive behavior.

## Causes of Domestic Violence

- Domestic Violence is _not_ loosing control
-           It is **taking** control

**Notes:**

	Domestic violence is not due to loosing control.  The pattern is not random. Batterers make specific choices and follow their own set of internal rules used for their abusive behavior.  Some hit in particular ways such as to hit on the face so a partner cannot or will not go to work and will be dependant on him for financial means. Another may not hit were it can be seen so that his action will remain unknown and so that the partner will not miss work. Some will only hit in private  Others will hit in public for the purpose of humiliating the victim. Objects that are destroyed during violent episodes do not belong to the perpetrator, but to the victim.   Some aspects domestic violence such as stalking and interrogating family members actually require planning to execute. Perpetrators selectively use tactic that work over their particular victims in order to establish dominance. This attention to detail contradicts the notion of loss of control

## III. victims

- Who are the victims?

## III. Who are the victims?

- Victims of domestic violence are often  the patients we see in our hospitals and clinics every day

**Notes:**
.
	Victims of domestic violence have numerous health problem that are caused by living an abusive situation. These can range from miscarriages, physical injuries, depression, suicidal ideational and attempts. Chronic pain syndromes are very common in victims of domestic violence and sexual assault.  Existing illness can be exacerbated by living in this stress rule life. In addition the perpetrator may display control interfering with access to medical care, hiding medications .
	As medical practitioners we are often the first or only professional than persons in abusive relationship may come in contact weight. Failure to identify a victim of abuse  creates and continues health consequences ,the health care provider has the unique the opportunity to identify intervene and even prevent domestic violence where other social systems may never have contact with the victim

## III. Who are the victims?

- Victims  can be found in all communities
- Victims come from all races, religions, sexual orientations, education levels, physical abilities and social groups.
- Can be male or female
- Can be adolescent to elderly

**Notes:**
	There is no specific personality  profile that can be identified for victims of abuse. There is not specific age group, racial, socioeconomic group, educational level or occupation, religious or sexual orientation that victims fall into
Often we try to stereotype victim into one group , but not another

	Victims can be male of female, in heterosexual relationships it 95 % female victims, 5% male.

	Relationship violence can occur in any age group. All to frequently we see homicide/ suicide stories in adolescents but violence can occur well into the later years.

## III. Who are the victims?

- Victims may or may not have been previously abused

**Notes:**

	In the past it has been suggested that victims of domestic violence have been victims of child abuse and or previous violent relationships.  There is however no evidence that previous victimization,  either as adults or as children, results in women seeking out violent relationships.
	Some women will say that they thought that was jus the way it was all men were like , that is what their mother and grandmother live through. This however is not true for all, many women in violent relationships grew up in non violent homes and have had no prior violent relationships.
	Labeling a victim as some one who seeks out a a abusive partner  contributes to the victim blaming  and we should be very cautious in this area.

## III. Who are the victims?

-      Some behaviors of victims seen in health care setting can be better understood in light of the control  the perpetrator has gained over her through isolation

**Notes:**

	A patient  who is in a violent relationship may be reluctant to commit to a complicated  treatment protocol that will require multiple appointments.  She may be isolated from transportation, or health care coverage.   She may lack confidence in her own abilities to care for herself do to diminished self esteem. Her abuser may interfere with use of medications controlling access to obtain them or throwing them away. In the face of medical “noncompliance”  abuse should be considered.

## III. victims

- Why do they Stay?

## Why do they stay?

- Many  victims do leave. This must be carefully thought out
- There are often numerous  barriers to leaving an abusive relationship  	some of these follow

## Why do they stay?

**Fear -** threats of suicide, homicide, threats to family or children

**Notes:**

	The most common reason given by victims of domestic violence for returning to or not leaving a violent relationship is fear of violence and lack of real options for safety for themselves or their children. This fear of violence is real. The victim may have left previously and been tracked down and brought back.  Some batterers repeatedly attempt to kill or seriously injure their victims, children and others when the victim attempts to leave the relationship. Perpetrators seldom just let the victim leave the relationship  
	Research shows that lethality of a batterers violence often increases when the perpetrator believes that the victim has left  or is about to leave. Indicators of increased for homicide include:
	Increased risk taking by the batterer, 
	threats to kill the victim and self, 
	substance abuse, 
	and a gun in the household.

## Myth

- Victims of Domestic violence Stay with their batterer because they like the abuse.

**Notes:**

	This is a myth some still hold to as an explanation for why women stay.  However even in cases where the victim was abused as a child, the victim does not seek out violence and does not want to be battered. Staying in  or returning to the relationship may simply be safer than leaving. 

## Why do they stay?

- Immobilization by psychological and physical trauma
- Illness and dependence on the perpetrator for health care

**Notes:**

	With continued psychological, emotional ,verbal  and physical abuse the victim may believe that she is to old to start over, to dumb to survive on her own and to undesirable to find a new partner.  Physical injuries incurred from the abuse can be barriers to leave creating dependence on the perpetrator for care, transportation, mobility or even drugs and alcohol for self medication of chronic pain related to abuse. 

## Why do they stay?

**Children-** “ He is the father of my children”, “I thought my children needed a father”
**Illness creating dependence on the batterer for health care**

**Notes:**

	Children are a major reason given for staying but are also a major reason for leaving.  Our society dictates that a child know his father.  There may also be issue of custody in which the children are used to keep the victim from leaving.  In Indian country we may see a victim who concern loosing her children in a custody fight because she is not a tribal member where the children are enrolled and the father is. She fears Tribal Court will give favorable custody to their own tribal member.

The batterer may also be the primary care giver for a patient with chronic debilitating illness such as multiple sclerosis or HIV. 

##    Why do they stay?

**Isolation-** social, family, geographical

**Notes:**

	A victim who is geographically isolated may be dependent on her abuser for transportation to and from the home. There may be no phone for the purpose of isolation. Others may have stayed with the batterer despite families ultimatum to leave and have been “kicked out” of the family.   Feeling they are unable to return to family creates yet another barrier.  A victim might not be allowed to make friends may be moved to a new town in order to isolate her and maintain control. This give barriers socially, familial and geographically.

## Why do they stay?

**Optimism****-** “I thought it would get better if he stopped drinking”, “He said he would never do it again”
- Belief that the batterer needs her for survival

**Notes:**

	We all live with the optimism that our life will improve. When I graduate, after we get married, when the baby is born, I f only had a car....The relationship  may not always be bad. There are the flowers ,the I love you and the it won’t happen again.  The victim may hold onto those rewards. She may believe as many do that the violence is caused buy alcohol or drugs and will stop if he stops using. She may believe as many do that she is the cause of the violence and that if she could just clean the house like he likes then he would have to hit her. 

With threats of suicide if she leaves , “I would die without you” ,” I would kill myself if you left” . She may also be a care giver for the batterer with chronic illness and fears he will die without her specific care.

## Why do they stay?

**Religious/ Cultural  beliefs/marriage vows- **“till death do us part”
- Insufficient Funding  and resources nation wide

**Notes:**

	There may be religious leader, family or pressure from self that marriage vows cannot be broken and  the family unit must be maintained at all costs.

Funding for shelter programs and victim advocacy group can limit the transitional support available to victims trying to leave.

## Why do they stay?

- Lack of real alternatives for employment and financial assistance
- Lack of affordable legal assistance
- Lack of affordable housing

**Notes:**

	In particular victims with children to support face these barriers. Funds must be stretched further in order to housing on some Native American Reservation housing and employment opportunities are very limited. Leaving to one homeland may mean leaving family, friends and culture.

## Why do they stay?

- Oppression
- Victim Blaming

**Notes:**

	A victim in a gay or lesbian relationship may be told that the abuse is happening because they are gay, lesbian or bisexual and the abuse would stop if they would change.  An abuser may also threaten to disclose the true nature of the sexual relationship to those the victim is not ready to tell.. 

The victim may be blamed and therefore unsupported by family, friends, counselors, courts, health care providers  and ministers. When a person of such perceived authority asks “What you do to make him angry?”, or suggest that the abuse would stop if the victim would comply with the batters wishes. Victims then learn that the systems in power do not believe or support them and they must be the problem.

## III. Victims

- Survival Strategies

## Survival Strategies

- Survival Strategies used by Victims of Domestic Violence often leave them labeled as crazy , codependent or with inappropriate behavior

**Notes:**

	Victims of domestic violence use many strategies to survive.  Some of these behaviors become inappropritately labled “crazy”, coodependent or inappropriate.  In the clinic situation a abused patient may present a demeanor of anger, be very demanding or manipulative. These things can be seen as coping strategies for maintaining distance and discovery of her violent relationship.  In addition it is a way of maintaining some control of her own life.
		A victim may seek to terminate her abusive relationship through legal resources only to  be told by courts that they must give the relationship more time.  She may be told by social service or advocates they do not qualify for needed services.  Police may refuse to enforce restraining orders.  In small, related communities batterers may have connections or relatives in positions of power that prohibit appropriate action for the victim.  When the victim discovers that the systems with power to intervene but will not act to safeguard and support  her, she may conclude that reconciliation with the perpetrator is the safer option.

## Survival Strategies

- Agreeing with denial or minimization in public
- Accepting promises

**Notes:**

	These approaches may seem like submission or passiveness but in reality the victim has learned that these are successful temporary approaches for avoiding or stopping the violence.  A victim may readily admit abuse but minmize it as a way to cope with what is happening until she can decide if the supports really exist that are needed inorder to safely leave.  Successful interventions must be based on an understanding of the vicitms behavior as a normal response to the violence perptrated inorder to survive.

## IV. Who are the perpetrators?

- Batterers come from all races, religions, sexual orientations, education levels, and social groups.
- Can be male or female
- Can be adolescent to elderly

**Notes:**

	Batterers  too come from all races, religions, sexual orientations, educational levels and social groups. They are found in all comunities and like their victims they do not fit into any one specific category.  Prevalence varies from one community to another, with race, religion, and country.  Acceptability among peers, social and legal consequences have a role in dictating prevalence.  Research on profiles of providers is currently too premature to be useful in identifieing and treatment.  There do however appear to be personality characteristics clusters that appear more often in batterers. 	

	Batterers can be male or female.  Estimates are that 95% violence in heterosexual relationships is male directed at female victim.  Batterers can be adolescent to elderly. Literature also suggests that there are different types of batterers who use different controlling tactics to different degrees.  Some of this variance may be due to evaluation in different stages in individual histories. 
	Perpetrators present with injuries related to the victims attempt to defend themselves. Others may present with injurious related to violence , such h as broken hands  from punching the victim, failed suicide attempts,  Illness such as diabetes and hypertension may be exacerbated by the abusive behavior as well. These persons present to medical providers and should be referred on to batter treatment programs.

## Who are the perpetrators?

- The one commonality is the tactics used to gram power and control l in the relationship

**Notes:**
Perpetrators minimize abusive behavior  and it is impact on the victim and others by making the abuse appear less frequent and less sever than it might actually be( I only hit her once, She bruises easily, The children never see) 
They may use other euphemisms to talk about the abuse. ( Were not getting along so well”)  

A perpetrator may acknowledge the abuse but move responsibly  for their actions and behavior to another person or thing
“ She wouldn’t listen to me,   She running around on me, I was drinking, Work ahs me really stressed , The EMT got his facts all wrong”
So will not lei about thief r behavior because they do not feel they are in the wrong. Others will lie about the abuse to avoid legal consequences (She wrecked the 4 wheeler)
These behaviors may also be use not only to avoid legal consequences but to protect themselves from the personal discomfort that they are hurting someone they love

Regardless of the reasons for the distortion of the truth it can be misleading to both the victim and the healthcare provider. Health car providers shoes always be aware of a perpetrators tendency to minimize ,lie or deny the violence.

## IV. Who are the perpetrators?

- Batterers are our patients

**Notes:**

	Perpetrators present with injuries related to the victims attempt to defend themselves. Others may present with injurious related to violence , such as broken hands from punching the victim, failed suicide attempts.  They also present with illness such as diabetes and hypertension may be exacerbated by the abusive behavior. If identified by the medical provider these patients should be referred on to batter treatment programs.

## Who are the perpetrators?

- Regardless of how we feel about  perpetrators they still may have good qualities
- The reality is that seemingly nice normal people can batter and may be very dangerous

**Notes:**
Perpetrators may be “excellent fathers but bad husbands”
They may be highly esteemed community members  of the community hard worked, witty and other wise charming 
Sometimes we as health care providers can be misled by these pleasing qualities and assume that the violence could not have reoccurred Thereby meaty believe that the violence can be overlooked because such a good person would certainly not do something so horrible intentionally

##      Control Through HealthCare

- Perpetrators may enlist others to aid them in control of their victim. These tactics may be used to coerce the victim to stop talking with the health care provider, to reunite them,  or to drop objections to joint custody

**Notes:**

	The following are examples of controlling behaviors that health care providers may witness;
 		Physical assaults or threats of violence against the victim, children, or sometimes health care provider,
		Threats of suicide, t
		Threats to take the children
		Harassment or stalking of the victim in the medical facility
		Accompanying the victim to the appointment, looks given during the appointment, 
			refusal to leave during the appointment
		Canceling or sabotaging attempts at appointments( refusing to help with child care, taking the car keys)
		Blaming the victim through long speeches to the provider
		Bringing in family and friends to the medical facility harass to the victim or health car provider
		Crying and emotional displays 
		Withholding medications 
		Using any evidence of damage of abuse as evidence that victim is unfit mother (depression )
		Continually testing limits of visitation agreements
		Using the legal system making false allegation so mutual abuse 

The perpetrator may also attempt s to control the provider through.....
		Excessive praise as of the provider with portrayal of himself ad the good patient
		Intimidation for the provider with threats of harm or law suit
		Harassment of the provider with threat soft suits, phone calls false reports 
		Attempts to split health car teams “ the doc is one of those women libbers”, “that nurse doesn't like me”

## V. Children are the                  silent victims ! 

- Domestic Violence _always_ effects the children!

**Notes:**

	Children Are often the forgotten victims of domestic violence. They are always affected by it despite that fact we may think they are sleeping or they are hiding and saw nothing.  Research indicates that the affects of domestic violence on children  are both short term and long term.  Children may be damaged physically, emotionally or cognitively.  The nature and extent of the damage will vary with the type and history of abusive control by the perpetrator; the age, gender  and developmental stage of the child and the situational factors such as other social supports

	Children in violent homes also appear in the health care system with a various of injuries, illnesses and medical conditions that may be directly related to the perpetrators abuse. Treatment of any medical condition may be complicated by and abusive controlling environment.

## Trauma and Terrorization of children

- Intentional injures
- Unintentional injures
- Children witnessing abuse
- Using children to control the victim

**Notes:**

	Children may be intentionally injured as a way of controlling or threatening  the victim, the child may be physically or sexually abused as a coercion for the victim to comply with wishes of the perpetrator.  A child might be injured being thrown at the victim. 
	Unintentional injuries may occur when children are caught in the attack, a baby held in the victims arms when she is pushed, or a child trying to protect his mother may be injured.
	Research reveals that children who witness domestic violence are affected in the same ways children who are sexually or physically abused.  Children often witness both physical and psychological abuse visually, audibly or  by seeing the aftermath of injuries and property damage.
	Using children to coercively control the victim can occur while living together or separated.  The intent is to continue abuse with little regard for the damage this behavior has on the children.  Batterers may assert that the abuse is due to bad behavior of the children,
	Children may be isolated form peer activates along with the parent, children may be made to participate in the physical and psychological abuse of the victim  or may be forced to watch the abuse.
Violence may be threatened against the children, pets or loved objects. These attacks against pets and loved objects are particularly traumatic for young children who cannot distinguish between themes and the pet or object. They may be interrogated about the abused parent or made to always be accompanied the parent. Children may be taken away after assaults on the victim to ensure that the victim will not flee.  Children may beheld hostage or abducted in order to punish the victim or gain compliance .there may be lengthy custody battle. long tirades directed at children about the abused parents behavior and the “causes” for the abuse.

## B. Effects on Children

- Infancy
- Crucial development of emotional attachments
- Forming attachments provides a foundation for healthy development

**Notes:**

	Domestic violence interrupts the infant's attachment to the perpetrator.  It can also interrupt the infants attachment to the victim. The perpetrator may interfere faith the victims care of the infant. The violence may not permit bonding  between either parent of child. This results in difficulty forming future relationships and blocks development of other age appropriate skills and abilities

## B. Effects on Children

- Children age 2-5 years
- Primary task of role development
- Primary task of cognitive development

**Notes:**

	Children in this age group may have difficulties learning basic concepts in school because of anxieties over events at home. This limits building blocks on which the child can continue his cognitive development

## B.  Effects on Children

- Teenage years
- Primary task is autonomy

**Notes:**

	Autonomy occurs as teens separate from relationships with parents and establish peer relationships. What is learned in family relationships is often duplicated in peer relationships. For teens living in violent homes there may be no positive model for learning skill soft establishing mutually healthy relationship. The teen may side with the abusive parent who is seen as the more powerful.  

## C. Health  Effects on Children

- Physical  injuries
- Abuse and Neglect
- Alcohol and Drug abuse
- Psychosomatic complaints
- stomachache, headache
- Sleeping disorders
- Eating disorders
- Suicidal attempts/Suicide

**Notes:**

	Like adults children experience a great deal of fear and have multiple  ways of expressing  that fear. These negative affects of the perpetrators abuse can be seen in cognitive, psychological  and physical symptoms.  Children can suffer physical injuries related to the violence whether it is directed at them or the victim parent.  Children in homes where there is violence between parents are 15 times more likely to be victims of child abuse than other children.
	Children who are using alcohol or drugs are most often self medicating to cover emotional physical  or sexual abuse of themselves or a parent.  Children like adults often internalize emotional pain this can be exhibited in headaches , stomach aches and insomnia.  Mothers of children showing psychological stress with these symptoms, signs of eating disorders, depression, suicide attempts or gestures should be asked about domestic violence.

## D. Mental Health Effects on Children

- Aggressive , acting out
- Destructive rages
- Detachment,
- Avoidance,
- Depression, mood disorders
- Post Traumatic Stress Disorder

**Notes:**

	Children may also act out their fear, anger and what they are witnessing in the home.  Children living with domestic violence  also results in changes in perception and problem solving skills. Young children may see themselves as the cause of the batterer behavior towards the victim. Children will use either passive behaviors such as withdrawal or compliance  or aggressive behaviors  such as verbal or physical  striking out  rather than assertive problem solving skills to cope with the problem.  50 to 70 percent of children exposed to domestic violence suffer from Post Traumatic Stress Disorder, a higher rate than either Vietnam Veterans or rape victims.

## E. Behavioral  Effects on Children

- Over compliance
- Clinginess,
- withdrawal
- Emotional neediness
- Restlessness
- Finger biting
- Stuttering
- shaking

**Notes:**

	All these things  demonstrate anxiety  and stress in the child's life.

## Domestic Violence and Children

- Domestic Violence

- 63 % of boys arrested for homicide, ages 11-20 have killed their mothers assaulter

- 80% of runaways come from homes where domestic violence occurs.

- 70% of offenders in treatment for domestic violence witnessed it as a child.

-    **Witnessing violence always has an impact on children!**

- nightmares

- depression

- Behavior problems

- fear

- Difficulty forming relationships

- Eating disorders

- withdrawal

** ****suicidal thoughts**

- Problems at school

- Aggressive acting out

- Increased use and abuse of drugs and alcohol

- detachment

- Destructive rages

- increased assaults

## F. Children and Domestic Violence

- Victims of abuse use numerous methods to protect their  children form the perpetrator off violence.

**Notes:**

	Removing the child from a loving caregiver is not the answer, nor is putting an adolescent in a treatment program without assign a safe home to return to. The most effective way to protect children is to protect the non abusing parent. Children do not have to harmed irreparably by experiencing domestic violence. A caring and supportive network can lessen the negative effects  to children, helping them rebuild their sense  of self as caring competent beings. Once they are safe children can return to normal developmental tasks.

## Add It All Up...

- 	Physical and sexual violence against women is a public health problem that has reached epidemic proportions.
- 				American Medical Association
-                                                Diagnostic and Treatment Guidelines
-                                                on  Domestic Violence, 1992

## Conclusion ...

- As health care providers  we play an important role in the coordinated community response to domestic violence. Understanding Domestic violence is Key to our addressing, identifying and intervening