Florida: Domestic Violence

Family and domestic violence, including child abuse, intimate partner abuse, and elder abuse, are prevalent problems in the United States, especially in Florida. Family and domestic violence are estimated to affect 10 million people in the United States annually. As a national public health problem, virtually all healthcare professionals will, at some point, evaluate or treat a patient who has experienced some form of domestic or family violence. Unfortunately, most forms of family dysfunction lead to interconnected forms of violence, and the cycle of abuse often continues from childhood in the affected children through adult relationships and finally to the care of older individuals. Domestic and family dysfunction include a range of behaviors, including economic, physical, sexual, emotional, and psychological abuse, affecting children, adults, and older individuals alike. Intimate partner violence can include stalking, sexual and/or physical violence, and psychological aggression by current or former partners. In the United States, as many as 1 in 4 women and 1 in 9 men are affected by domestic violence. Domestic violence is thought to be underreported, impacting the affected person and their families, coworkers, and community. The violence causes diminished psychological and physical health, decreased quality of life, and reduced productivity. The national economic cost of domestic and family violence is estimated to exceed $12 billion per year. The number of individuals affected is expected to rise over the next 20 years with an increase in the abuse of older adults. Domestic and family violence is difficult to identify, and many cases go unreported to healthcare professionals and legal authorities. Due to its prevalence in our society, all healthcare professionals, including psychologists, nurses, pharmacists, dentists, physicians, physician assistants, and nurse practitioners, will, at some point, evaluate and treat an affected person or perpetrator of domestic or family violence. 1. What are the risk factors, signs, and symptoms of domestic or family violence? 2. What are the characteristics that define domestic or family violence? 3. What information helps healthcare professionals address the needs of patients affected by domestic or family violence? 4. What are the ethical and legal reporting requirements? Healthcare professionals should be able to identify potential abusers. Healthcare professionals should be able to assess all patients for abuse and offer counseling, education, and referral. Survivors of domestic and family violence may suffer emotional, physical, and psychological abuse and need empathy and understanding. Healthcare professionals must be able to identify the signs and symptoms of a mental and physical disease, illness, and injury related to domestic and family violence and provide initial counseling. Injuries often require immediate evaluation and treatment after an assault. As a result, clinicians are usually the first to evaluate and identify persons affected by violence. All healthcare professionals need to be aware of the presence of affected persons in their clinical settings. Upon identifying domestic or family violence, healthcare professionals should have a plan that includes providing community resource information related to shelter, counseling, advocacy groups, child protection, and legal aid. Family and domestic violence is the perpetration of abusive behaviors when an individual or individuals gain power over another individual or individuals. Intimate partner violence typically includes sexual or physical violence, psychological aggression, and/or stalking. This may consist of the exposure to violence of former or current intimate partners. Child abuse involves the emotional, sexual, or physical abuse or neglect of a child aged 18 or younger by a parent, custodian, or caregiver, resulting in potential harm, actual harm, or threat of harm. Elder abuse is a failure to act or an intentional act by a caregiver that causes or creates a risk of harm to an older individual. Domestic violence, spousal abuse, battering, and intimate partner violence are terms used to describe the exposure to violence of individuals with whom an abuser has an intimate or romantic relationship. The Centers for Disease Control and Prevention (CDC) defines domestic violence as "physical violence, sexual violence, stalking, and psychological aggression, including coercive acts, by a current or former intimate partner." Violence occurs in intimate relationships regardless of culture, race, religion, or socioeconomic status. All healthcare professionals must understand that domestic violence, whether emotional, psychological, sexual, or physical, is common in our society, and members of the multidisciplinary team should recognize and make the appropriate referrals. Domestic violence is defined by the Florida Department of Children and Families as "a pattern of behaviors that adults or adolescents use against their intimate partners or former partners to establish power and control. This may include physical, sexual, emotional, and economic abuse. In addition, it may also include threats, isolation, pet abuse, using children to manipulate the situation, and a variety of other behaviors used to maintain fear, intimidation, and power over one's partner." Domestic violence under Florida law is defined as "any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of a family or household member by another family or household member." Family members must "reside in the same single dwelling unit, except for persons who have a child in common." Violent abuse takes many forms, including stalking and economic, emotional, sexual, physical, or psychological abuse, as well as neglect and Munchausen syndrome by proxy. Domestic and family violence occurs in all races, ages, and sexes without cultural, socioeconomic, educational, religious, or geographic limitations. This violence can affect individuals of different sexual orientations. Stalking is repeated, unwanted attention that causes fear or concern for safety. Behaviors include unwanted letters, emails, texts, or phone calls; watching, following, or spying; repeatedly showing up in the same place; damaging property; and making threats of harm. Economic or financial abuse occurs when an individual is forced to depend on an abuser through improper use of money by a person in a trusting relationship. The abuser may forbid employment or education to gain additional financial control. Examples include coercion to surrender, forgery, theft of possessions, and improper use of guardianship or power of attorney. Emotional or psychological abuse includes verbal and nonverbal communication that inflicts emotional or mental harm. This type of domestic violence may be subtle but is still harmful to the survivor, often resulting in depression and suicidal thoughts. Emotional or psychological abuse may involve convincing the survivor that the violence is their fault, that no solution exists, and that they are worthless and need the abuser to exist. Many abusers will isolate their targets from friends, family, school, and work. Examples of emotional or psychological abuse include: Child relationship control: Damaging a relationship with a child deliberately. Coercive: Limiting resource access, possessiveness, and constant monitoring. Exploitation: Using consequences to control choices, for example, "If you call protective services, I could go to jail, and you will have no financial support.". Expressive: Name-calling, degradation, and threats. Gaslighting: Presenting false information, making the survivor doubt their memory and perception, and making the survivor question their sanity. Reproductive control: Refusing birth control or forced pregnancy terminations. Threats: Using gestures, words, or weapons to suggest that future harm may occur. Sexual violence involves using physical coercion to force participation in unwanted sex acts. Perpetrators may incapacitate targets with alcohol or drugs.  Categories of sexual abuse may include: Forced anal, oral, or vaginal penetration of a target. Forced penetration of someone else. Sexual coercion involving intimidation to pressure consent. Unwanted exposure to pornography, harassment, sexual violence, filming, taking, or disseminating sexual photographs or videos. Unwanted sexual contact. Neglect occurs when an individual responsible for the well-being of a child or an older individual ignores that well-being. Neglect is the failure to provide for a dependent's emotional, physical, or social needs, including hygiene, nutrition, clothing, shelter, and access to health care. Abandonment is also a form of neglect. Munchausen syndrome by proxy is a factitious disorder where an individual fabricates or exaggerates mental or physical health problems in the person for whom they care. The primary motive is to gain attention or sympathy. Unlike Munchausen syndrome, the deception involves someone, not themselves, under the person's care. The use of physical power that results in injury, disability, or death is a form of physical violence. Other forms of physical violence include coercion, administering drugs or alcohol without permission, and denying medical care. Examples of physical abuse include: Assault. Biting. Burning. Choking. Gagging. Grabbing. Kicking. Punching. Hair pulling . Restraining. Scratching. Shaking. Shoving. Slapping. Usually, abuse begins with verbal threats that escalate to physical violence. Violent events are often unpredictable, and the triggers for the targets are unclear. Affected individuals live in constant fear of the next violent attack. Violence and abuse are perpetrated in an endless cycle involving 3 phases—tension-building, explosive, and honeymoon. In this phase, the abuser becomes more judgmental, temperamental, and upset, causing the target to feel like they are "walking on eggshells." Eventually, the tension escalates until the abuser explodes. During this phase, the target may attempt to calm the situation, stay away, or reason with the abuser to no avail. The abuser exhibits moodiness and unpredictability, resorting to screaming, threats, and intimidation. They may also use children as tools for intimidation and engage in alcohol and drug use. During this phase, the target may attempt to protect themselves and their family by contacting authorities. This phase often results in injuries to the affected person. The abuser may begin by breaking items and escalate to striking, choking, and rape. The affected person could be subjected to imprisonment. Emotional, verbal, physical, financial, and sexual abuse are common. In this phase, the affected person may initiate counseling, seek medical attention, and agree to halt legal proceedings. They may mistakenly believe and hope that the situation will not recur. However, this hope is often unfounded. The abuser may apologize, agree to counseling, beg for forgiveness, and give presents. They may declare their love for the target and family and promise to "never do it again."