Intimate Partner Violence: Compassionate Care, Effective Assessment _ _______________________________
Some patients meet criteria for human trafficking, even if they don’t identify themselves as trafficking victims. Trafficked people, like IPV patients, often do not accurately perceive their status. They may view their situation, for example captivity, as a requirement for being brought into the country or an expec- tation they must obey. Adolescents are groomed by traffickers who may call themselves “boyfriends,” “daddies,” or romantic partners. Key tactics of manipulation and entrapment include seduction, gifts, and actions made to look like emotional sup- port. Once the trafficker creates a romantic connection, the victim is coerced into engaging in commercial sex acts. Federal anti-trafficking laws exist and clinicians should be familiar with their general principles [46]. CHILD-RELATED ISSUES Observing or hearing violence can be traumatic and damag- ing for children of all ages. Prolonged, severe, and repeated stress adversely affects brain development in young children. Witnessing violence affects children’s abilities to focus and learn in school, form healthy peer relationships, and develop normally. Witnessing violence may exacerbate health problems such as asthma, eating disorders, or behavior problems such as bedwetting. Many children exposed to IPV have a distorted view of the world, one that is not hopeful, welcoming, or safe. They have a foreshortened view of their lives, in which they cannot picture themselves as adults, or see a future for themselves. Adolescents who grew up in violent homes are more likely to be involved with substance abuse and dating violence. Children who witness family violence are also at greater risk of being physically harmed themselves, especially if they attempt to defend or protect the abused individual during an assault [48]. An estimated 15.5 million children are exposed to IPV annually, and approximately 1 in 4 children are exposed to IPV before age 18 [49]. Children, like adults, may find it difficult to talk about the violence in their lives, and thus become “silent victims.”48 Clinicians need to attend to children’s needs for safety and security as well as provide support and interventions for physi- cal and mental health problems. Appropriate assessment and intervention can help children learn that violence perpetrated by anyone, especially by a family member or loved one, is wrong and unacceptable. Efforts such as these can serve as a crucial link to help children cope with, and recover from, the devastating effects of exposure to IPV. Violence is, in part, a learned behavior. Although most abused and neglected children do not become victims or perpetrators as adults, research has shown that up to 75% of men in batterer intervention programs report witnessing the abuse of their mothers, or being physically abused themselves as children [50]. Girls who have been abused or neglected, or who have witnessed the abuse of their mothers, may be more likely to become victimized in their own adolescent or adult relation- ships. Abused and neglected children also are at greater risk
for exhibiting delinquent, violent, and criminal behavior as well as long-term health problems [51; 52]. Disclosure of IPV may herald a particularly dangerous period for both survivors and children. Therefore, once disclosure is made, particular attention must be paid to the safety and well- being of the children and of others living in a home in which IPV is occurring. If a health care provider suspects physical, sexual, or emotional abuse or neglect of children, contact the Department of Children and Families’ (DCF) Child Abuse and Neglect Careline (1-800-842-2288). Child Protective Ser- vices can then consult with specialists in IPV to take action to protect both the adult survivor and the child or children. In addition, the clinician should communicate the decision to contact DCF, and the reasons for doing so, to the survivor. Such a conversation, although difficult to initiate, can help to establish trust and promote safety for both survivors and children. ELDER ABUSE Healthcare providers can be pivotal in the detection, man- agement, and prevention of elder abuse. Understanding the dynamics of elder abuse is crucial to breaking the intergen- erational cycle of this form of abuse. Approximately 1 in 10 Americans over the age of 60 have experienced some form of elder abuse. Elder abuse can include physical and sexual abuse, emotional abuse, confinement, passive neglect, willful deprivation, and financial exploitation [1; 53]. Abused or mistreated elders may only come to the attention of clinicians after having been abused for years or even decades. Some elderly individuals exhibit signs and symptoms of current or past domestic violence. Patients no longer in acute danger may nonetheless suffer long-term morbidity from past abuse. For independently living elders, fear of being placed in a nurs- ing home and losing autonomy may limit disclosure of abuse. Clinicians who care for elders often have established and trust- ing relationships with their patients. Clinicians and extended care providers who provide home care can observe behaviors and conditions that can lead to earlier intervention in at-risk patients. All healthcare professionals should remain mindful of their mandated reporter responsibilities as they evaluate elderly at-risk patients. CASE STUDY 3 Shanice is an 18-year-old female presenting for an annual exam. Her BMI is 35, and she is diabetic. She reports that she has not been tak- ing the metformin prescribed last year because she lost it and couldn’t afford to buy more. She has a history of alcohol and opioid abuse; she reports that her last opioid use was at a party the previous weekend. Her exam today reveals that she is approximately 5 months pregnant. Shanice is devastated to hear this information; she already has a 2-year-old and doesn’t want to be pregnant again. She has bruises on her upper left arm as well as discoloration and mild swelling on one side of her face. Upon inquiry, you discover she dropped out of school when her first child was born, recently lost her job, and lives with “a
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