subsequent violence. Clinicians should inform their patients of the option and the process of obtaining a protection order, but respect their judgment about whether or not such an order will enhance safety. State-by-state information about civil protection orders (CPOs) is available at: https://www. americanbar.org/content/dam/aba/administrative/ domestic_violence1/Resources/charts/cpo2020. pdf Additional Legal Options Additional legal options for IPV survivors include divorce, legal separation, annulment, and child and spousal support orders. Division of property or awards of financial support can be critical to enable the survivor and dependent children to live independently from the batterer. Abused immigrant women often face particular obstacles, as they may be relying on coercive partners to assist them in obtaining legal status. Abused immigrants who are married can apply for permanent status independent of an abusive partner, and documentation of the abuse from a physician can be extremely important in that process. Immigrant patients who are abused by partners should be referred to an IPV, domestic violence, or immigration advocacy program for Healthcare providers must comply with relevant requirements regarding the implementation of IPV protocols and educational programs. The Joint Commission on Accreditation of Healthcare Organizations’ standards call for identification and assessment of abuse victims, appropriate documentation, intervention and referral, and staff education. 54 Some states have enacted laws mandating IPV protocol development or training for providers in practice (e.g. required continuing medical education credits) and in professional schools. Mandatory Reporting assistance with such proceedings. Legal and Regulatory Issues for Clinicians Related to IPV Most states require healthcare providers to file a report to a state criminal justice or public health agency when a patient has an injury that appears to be caused by a weapon. States may also mandate reporting of injuries due to criminal acts, acts of violence, or non-accidental acts. Since IPV injuries are sometimes caused by weapons and involve crimes, these laws may apply. Some states have laws that specifically address reporting of suspected IPV. Laws vary from state to state regarding such factors as who must report, the degree of suspicion that triggers a report, to whom reports are made, penalties for failure to report, and immunity from liability for clinicians who make reports in good faith. A state may also have case law governing liability for failure to report abuse or for reporting when not required by law. Unlike pediatric child abuse reporting, IPV- related reporting needs to occur in a collaborative fashion with the patient. Not doing so has potentially harmful consequences. Reporting without the patient’s knowledge or consent—even when
required by law—may put abused individuals at risk of retaliation from the batterer, and thus may deter survivors from seeking health care or being candid with their clinicians about the cause of their injuries. Reporting without patient consent also infringes on patient autonomy and may further victimize an abused person. The abrogation of physician-patient confidentiality that may result from unrequested reporting may undermine the patient’s trust in the physician and in the healthcare system as a whole. While required to comply with all legal requirements, clinicians should strive to minimize the potential harms of laws that may place patients in danger. Most importantly, clinicians and their staff should provide ongoing, supportive care, address patient safety, and educate the patient about available options and community-based resources. Treatment Options for Abusers Although the focus of this learning activity, and of much of the medical, cultural, and sociological efforts over the past several decades, has been on the survivors of IPV, professional attention may also be necessary for the perpetrators of violence, their own problematic emotional conditions, and the need for interventions with abusers that may reduce future violence. 50 Edward Gondolf summarized and published an evaluation of programs for perpetrators of domestic violence, as well as data from his own large national study. 50 The vast majority of offenders will not seek help voluntarily; most come into an intervention program only as the result of a court order. The second most frequent way that offenders enter a program is when their partner has “mandated” intervention, often by leaving with a condition that the partner enrolls in an intervention program before returning to the relationship. It is also important to realize that even once ordered, many offenders choose not to participate or will drop out before program completion. Monitoring by a probation office/agent or another official within the court system is needed to ensure that if the offender does not complete treatment, there will be additional legal sanctions. Studies have shown that among men who complete treatment, a significant percentage are not reported to engage in violence during the following year. The percentage remaining nonviolent varies from 53% to 85%, with lower rates reported in studies based on survivor reports of violence. 50 Men who drop out of treatment are significantly more likely to continue to be violent than men who complete the treatment. Substance abusers are also more likely to continue to be violent, and substance abuse treatment may be needed in addition to offender intervention programs. In fact, research has shown that both treatment modalities are needed; substance abuse treatment alone will not end the violence, and abuser intervention alone will not address substance abuse problems. In some clinical trials, the mean difference in violent acts has not been significantly different between those attending programs and those not, showing that although some offenders do indeed improve, others do not.
The Legal Dimensions of IPV A number of legal remedies are available to survivors of IPV. Clinicians should familiarize themselves with these options so that they can inform at-risk patients. Because state laws change over time, and vary from state to state, the following information is a general guide only. Legal statutes by state are available at Womenslaw.org (https:// www.womenslaw.org/laws/statutes). Providers should obtain more detailed information from community domestic violence programs, their state medical board, or their state attorney’s general regarding laws and policies in their jurisdictions. Health facilities’ IPV referral lists should include resources for free legal services for economically disadvantaged patients, bar association referral services, legal advocacy services in intimate partner violence agencies and shelters, criminal justice advocacy programs, and immigration assistance organizations. The US Department of Health and Human Services offers detailed information and resources on the legal aspects of IPV (https://www. childwelfare.gov/topics/systewmwide/domviolence/ overview/legislation-policies/). Criminal Justice Relief Many, but not all, abused patients are considered to be crime victims. Such crimes may include assault, battery, rape, stalking, threats, false imprisonment, destruction of property, weapon crimes, and specific “intimate partner violence” crimes. Legislation such as the National Violence Against Women Act has been passed to improve the criminal justice response to violence against women. Clinicians should inform at-risk patients that what occurred may be a crime and that they may consider calling the police. Whether calling the police will result in arrest, prosecution, and/or jail time will depend on prevailing laws and policies, as well as the attitudes and practices of the individuals handling the case. Some communities have created dedicated IPV units within police departments. Clinicians should find out who the best police representative is to call in IPV situations in their community so that information can be made readily available for patients. The more informed the survivor is regarding legal rights when navigating the criminal justice system, the better off they will be. Civil Protection Orders The types of protection orders that are available to survivors vary from state to state and may include: restraining the abuser from further violence, requiring the abuser to vacate the household, ordering no contact with the victim, confiscation of firearms, withdrawal of child custody, requiring attendance in a batterer intervention program, and awarding the survivor compensation for medical bills and other expenses incurred as a result of the violence. Violation of a protection order is a felony in some states and may result in incarceration. Though police, prosecutors, and judges may not always respond adequately to protection order violations, such orders may reduce
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