Physical,sexual,oremotional/psychologicalviolencedirectedtowardmen,women,children,oreldersoccurringincurrentorpastfamilialorintimaterelationswhethertheindividualsarecohabitingornotandincludingviolencedirectedtowarddatingpartners(AACN,2001,p1)

Domesticviolenceisbestunderstoodwithinaculturalcontext(Campbell,Moracco,&Saltzman,2000;Hoff,2001)Forexample,TheBeijingDeclarationandPlatformforAction,resultingfromthe1995FourthWorldConferenceonWomenstressed,"Violenceagainstwomenderivesessentiallyfromculturalpatterns,particularlytheharmfuleffectsofcertaintraditionalpracticesandallactsofextremismlinkedtorace,sex,languageorreligionthatperpetuatewomen'slowerstatus"(UnitedNations,1995,p7)Campbelletal(2000)arguedthatviolenceresearchdemandsaculturalcompetencythatextendsbeyondculturalsensitivitytoincludeanin-depthappreciationofgroupnorms,beliefs,andlifewaysCulturalcompetencyisreflectedbytheacknowledgmentthatviolenceoccursinagenderedsocioculturalcontext,anunderstandingoftherelationshipbetweencolonialpracticesandviolenceandoppression,anawarenessofculturalpracticesandattitudesthatsupport,aswellasdeter,domesticviolence,advocacyforcross-culturalresearch,andacommitmenttoopposeoppressionexperiencedbyminoritygroupsandthosemarginalizedbytheirsociety(eg,womenofcolor,migrantwomen,immigrantwomen,andlesbianwomen)(Campbell,Campbell,1996;Campbelletal,2000,Hoff,2001)

Domesticviolenceisassociatedwithvariedandsignificanthealth-relatedconsequencesInadditiontoimmediatephysicalinjuriesstemmingfromanassaultandacutepsychologicaldistressrelatedtovictimization,domesticviolenceisassociatedwithlong-termpsychological,physical,social,andeconomiceffectsNursesandotherhealthcareprovidersplayakeyroleindomesticviolenceidentificationandinterventionandhavebeenvisibleadvocatesforthepreventionofdomesticviolencethroughouttheworldManyhealthcareprofessionalshavehadpersonalexperienceswithdomesticviolenceandareforcedtoconfronttheirownconcernsrelatedtoviolenceastheyattempttohelpothers

Thisarticlewillprovideanoverviewofthethreemajortypesofdomesticviolence:intimatepartnerabuse,childabuse,elderabuseThescope,history,andhealthconsequencesofeachtypeofviolencewillbedescribed

Spouse/partnerabuse

Walker(1999)arguedthat"thesinglemostpowerfulriskmarkerforbecomingavictimofviolenceistobeawoman"(p23)Whilestrangersoracquaintancescommitthemajorityoftheassaultsagainstmen,womenaremuchmorelikelytoberaped,assaulted,ormurderedbyromantic/intimatepartners(Mahoney,Williams,&West,2001)

Unlikestreetviolence,domesticpartnerviolenceoccursinthecontextof"shared"lives

Intimatepartnerabuseincludesabusebycurrentorformerspousesorromanticorco-habitatingpartnersPartnerabusedoesnottypicallyinvolveasingleviolentassault;itisacyclic,progressiveprocessinwhichviolenceisusedtocontrolone'spartnerMostviolenceagainstwomenbymalepartnersisbestdescribedasbattering-thatis,"apatternofbehaviorsthroughwhichonepersoncontinuallyreinforcesapowerimbalanceoveranotherinanintimate/romanticrelationshipcontext"(Mahoneyetal,2001,p15)Intimatepartnerabuseincludesavarietyofabusiveandcoercivebehaviorsthatmaybeofaphysical,psychological,sexual,oreconomicnature(Ganley,1998)Itisestimated,forexample,that0to5%ofbatteredwomenalsoexperienceforcedsexbymalepartners(Campbell,1998)

Unlikestreetviolence,domesticpartnerviolenceoccursinthecontextof"shared"livesInadditiontoaffectiveties,thevictimandtheperpetratorshare,orhaveonceshared,aresidence,financialobligationsandresources,children,and/orfriendsTheabuseoftenoccursinthecontextofanon-goingorrecentlyseveredrelationship;perpetratorsmaythereforehaveon-goingaccesstothevictimBecauseintimatepartnerviolenceisconsidereda"familyconcern,"itisoftentakenlessseriouslythanstrangerorstreetviolenceVictimsoftenexperiencesocialandeconomicbarrierstoendingtherelationship(Ganley,1998)

Scope

Manyhealthcareprofessionalshaveexperienceddomesticviolenceintheirpersonallives

FindingsfromtheNationalViolenceAgainstWomenSurvey,atelephonesurveyofanationalrandomsampleof8,000USmenand8,000USwomen,indicatedthatapproximately221%ofthesurveyedwomenwerephysicallyassaultedbyacurrentorformerspouse,co-habitatingpartner,boyfriendorgirlfriend,ordateintheirlifetime;13%ofthesurveyedwomenreportedsuchviolenceduringthepreviousyearBasedonthesefindingsandUSCensusdata,theresearchersestimatedthatapproximately13millionwomenarephysicallyassaultedannuallybyanintimatepartnerorex-partnerInaddition,77%ofthesurveyedwomenwererapedbyacurrentorformerintimatepartneratsometime;02%experiencedsuchviolenceinthepreceding12monthsItisestimated,therefore,thatover200,000womenarerapedeachyearintheUnitedStatesbyanintimatepartner(Tjaden&Thoennes,2000a)

ManyhealthcareprofessionalshaveexperienceddomesticviolenceintheirpersonallivesEllis(1999)surveyed0registerednursesemployedinalargeemergencydepartmentandfoundthat575%reportedapersonalexperiencewithdomesticviolenceWhile35%reportedhavingbeenhit,kicked,orpunched,only25%ofthisgroupidentifiedtheseexperiencesasabuseInasurveyof275nursesinperinatalpractice,31%reportedabuseofthemselvesortheirfamilymembers(Moore,Zaccaro,&Parsons,1998)

SignificantcontroversyexistsabouttheprevalenceandthenatureoffemaleviolenceagainstmalepartnersSomeexpertsmaintainthatwomenareasviolentasarementotheirpartners,whereasothersmaintainthatfemaletomaleviolencedifferssignificantlyinbothfrequencyandseverity,andisoftenusedinself-defense(Tjaden&Thoennes,2000b)ResultsoftheNationalViolenceAgainstWomenSurveysupportthelatterviewWhereas221%ofthewomensurveyedhadbeenphysicallyassaultedbyacurrentorformerpartneratsometime,only7%ofthemenhadexperiencedsimilarviolenceWomenwerethusmorethan29timesaslikelyasmentoreportabusebyapartneroftheoppositesexSurveyresultsalsoindicatedthatthefrequencyofvictimizationwasgreaterforwomen(71incidentsvs7incidents),aswasthedurationoftheviolence(38yearsvs33years)Thefemalevictimsalsoexperiencedsignificantlymorelifethreats(33%vs26%)andfearofbodilyinjury(5%vs20%)Theauthorsconcludedthatmaleandfemaleviolenceinrelationshipsisasymmetricalaswomenexperiencemale-perpetratedviolencemorefrequently,andtheabuseismorerepetitiousandphysicallyinjurious

History

AccordingtoEnglishcommonlaw,womenwereviewedaschattel-firstaspropertyoftheirfathers,andthenoftheirhusbandsWhenawomanmarried,herlegalexistencewasconsolidatedintothatofherhusband;shewasconsideredtobeunderhisprotectionandinfluenceandcouldnotinheritproperty(Schornstein,1997)PhysicalviolencewasusedfrequentlybyhusbandsagainstwivesAccordingtothe"ruleofthumb"law,amancouldbeathiswifewitharodnobiggerthanhisthumb(Barnett,Miller-Perrin,&Perrin,1997)

Schornstein(1997)providedseveralexamplesof19^thcenturyUScourtrulingsthatreflectedtheprinciplesofEnglishcommonlawandupheldtherightofahusbandtophysicallydisciplinehiswifeIn186,theSupremeCourtofNorthCarolinaruledinStatevBlackthatahusbandcouldnotbeconvictedofbatteringhiswifeunlessheinflictedapermanentinjury,usedexcessiveviolence,orexhibitedmalignityorvindictivenessIn1868,theSupremeCourtofSouthCarolinainStatevRhodesrefusedtoholdahusbandcriminallyresponsibleforhavingbeatenhiswifewithasmallstick

Inthelate1800s,legalreformrelatedtodomesticviolencebeganintheUnitedStates(Barnettetal,1997)Inthe1870s,AlabamaandMassachusettsintroducedthefirstlegislationmakingitillegaltobeatone'swifeSeveralotherstatesfollowedwithsimilarlegislationFewarrestsweremade,however,anddistrictattorneyswereunlikelytoprosecuteIn1882,thestateofMarylandpassedlegislationthatoutlawedwifebeatingandmadeitacrimepunishableby0lashesorayearinjail(Schornstein,1997)

GrassrootsfeministsbroughttheproblemofviolenceagainstwomentopublicattentionintheUSinthel960sand1970sandbegantoestablishanumberofcommunity-basedprogramsforbatteredwomenHavenHouseinPasadena,California,thefirstshelterforbatteredwomenandtheirchildren,wasopenedin196OrganizationssuchastheNationalOrganizationofWomenandtheNationalCoalitionAgainstDomesticViolencepushedforsocialservicesandlegislativereformtobetterprotectbatteredwomen(Barnettetal,1997)

In1979,LenoreWalkerpublishedTheBatteredWoman,aninfluentialbookthatdefinedthebatteredwomen'ssyndrome(BWS)ThemajorcomponentsofBWSarethepost-traumaticstresssymptomsandlearnedhelplessnessthatdevelopwhenthewoman'sattempttoendtheabuseprovesfutileWalker'sworkwassignificantasthesymptomsexperiencedbybatteredwomenwereidentifiedasresponsestoon-goingabuse,challengingthetraditionalassumptionthatawoman'spsychologicalvulnerabilitycausesorcontributesto,ratherthanresultsfrom,herbattering

In1982,theUSCommissiononCivilRightspublishedareportentitledUndertheRuleofThumb:BatteredWomenandtheAdministrationofJusticeevaluatingthetreatmentofvictimsofdomesticviolencebythecriminaljusticesystemandsocialserviceagenciesThereportconcludedthatpoliceofficers,prosecutors,andjudgesprovidedlittlereliefforvictimsofdomesticviolencebecausetheyconsidereddomesticviolenceaprivatematterratherthanacrime(Schornstein,1997)

TheformerUSSurgeonGeneral,EverettKoop,designatedthebatteringofwomenasasignificanthealthproblemandconvenedTheSurgeonGeneral'sWorkshoponViolenceandPublicHealthin1985(USDHHS,1986)The150attendeeswereadvocates,practitioners,educators,andresearchersconcernedwithviolenceagainstwomenMandatorytrainingandexaminationofhealthprofessionalsintheessentialsofdomesticviolenceinterventionwasamajorrecommendationfromtheworkshop(Hoff,2001)

In199,CongresspassedtheViolenceAgainstWomenAct(VAWA)asapartoftheViolentCrimeControlandLawEnforcementActTheVAWAisa"groupofindividuallyconceivedlegislativepiecesthatwerejoinedtogethertocreateapackageoffederallawsandgrantprogramsspecificallyaddressingdomesticviolence,sexualassault,andstalking"(Valente,Hart,Zeya,&Malefyt,2001,p285)TheVAWAwasthefirstfederallawtocriminalizedomesticviolenceThelegislationauthorizedgrantstostates,NativeAmericantribunals,andlocalgovernmentstoimprovecriminaljusticeresponsetodomesticviolenceItincludednewfederalstatutesforinterstatedomesticviolence,introducedacivilrightscauseofaction,fundedawideassortmentofprograms,initiatednewfederally-fundedresearchondomesticviolence,andcreatedanationaldomesticviolencehotline(Schornstein,1997)In1995,theViolenceAgainstWomenOfficeoftheOfficeofJusticeProgramswascreatedtoimplementtheVAWA(USDepartmentofJustice,2001)

Sincethe1970s,nursinghasbeeninvolvedineffortstocombattheproblemofintimatepartnerabuse

TheViolenceAgainstWomenActof2000,whichwasamendedtotheVictimsofTraffickingandViolenceProventionActof2000,reauthorizedcriticalgrantprograms,establishednewprograms,andstrengthenedfederallawsrelatedtodomesticviolence,sexualassault,andstalkingVAWA2000providescoveragefordatingviolence,supervisedvisitationcenters,civillegalassistanceandjudicialeducation,andincreasedprotectionforbatteredimmigrantwomen(USDepartmentofJustice,2000)

Sincethe1970s,nursinghasbeeninvolvedineffortstocombattheproblemofintimatepartnerabuseNurseswerestronglyrepresentedattheSurgeonGeneral's1985workshopTheNursingNetworkonViolenceAgainstWomenInternational(NNVAWI),whichaimsto"endviolenceagainstwomen,empowerbatteredwomen,andchangethehealthcaresystemtobemoreresponsivetotheneedsofabusedwomenandtheirchildren"(Campbell&Parker,1999,p51)wasfoundedin1986In1997,thePublicHealthServiceOfficeonWomen'sHealthcoordinatedaNationalNursingTaskForceonViolenceAgainstWomenwithmembersrepresenting30nationalnursingorganizationsThegroup'sworkresultedinnationalpolicyrecommendationsthatwerepresentedduringtheNationalNursingSummitonViolenceAgainstWomen(USPublicHealthService,2001)Severalnursingorganizationshaveissuedpositionstatementsacknowledgingviolencerecognition,prevention,andinterventionashealthcarepriorities(theAmericanAssociationofCollegesofNursing,2001;theAmericanNurses'Association,1991;theNationalBlackNurses'Association,Inc,199;theAmericanCollegeofNurse-Midwives,1997;theEmergencyNursesAssociation,1998)Duringthe1990s,therehasbeenaproliferationofprogramsinhospitalsandcommunity-basedhealthcentersthatprovidespecializeddomesticviolencepreventionandinterventionprogramsforbatteredwomenandtheirchildren(Sheridan,1998)

HealthConsequences

Thephysicalconsequencesofbatteringrangefromminorinjuriestopermanentdisability,disfigurement,anddeathTheNationalViolenceAgainstWomenSurveyfoundthat302%ofthewomeninjuredduringtheirmostrecentphysicalassaultand356%ofthewomeninjuredduringtheirmostrecentrapereceivedsometypeofmedicaltreatmentWomenwhoareassaultedorrapedbyacurrentorformerpartnerareatthegreatestriskforinjury(Tjaden&Thoennes,2000a)Nurseresearchershavedocumentedthat22%to35%ofwomenwhoseektreatmentathospitalemergencydepartmentsdosoforinjuriesrelatedtodomesticviolence(Campbell,Pliska,Taylor,&Sheridan,199)

Domesticviolenceinjuriesfrequentlyincludelacerations,bruisesandcontusions,musculoskeletaldamage(brokenbones,tendon&ligamentinjuries),neurologicalproblems(hearingandvisionloss,impairedconcentration),and,inthecaseofsexualassault,vaginalandanaltears(Warshaw,1998)Stress-relatedconsequencesofbatteringmayincludepersistentheadaches,chronicirritablebowelsyndrome,chronicpain,andeatingdisorders(Campbell,1998;Warshaw,1998)Sexualviolencemayresultinincreasedriskforanumberofgenito-urinaryproblems,includingpelvicinflammatorydisease,sexually-transmitteddiseases,bladderinfections,sexualdysfunction,pelvicpain,andurinarytractinfectionsBatteringduringpregnancyisalsoconsideredamajorhealthrisk,andmayresultinmiscarriages,placentalseparation,antepartumhemorrhage,fetalfracture,ruptureoftheuterus,andpretermlabor(Warshaw,1998)Batteringduringpregnancyhasbeenassociatedwithlowbirthweightinfants,perhapsthroughtheinfluenceoffactorssuchassmoking,lowweightgain,andsubstanceabuse(Campbelletal,2000)Mentalhealtheffectsmostfrequentlyassociatedwithbatteringincludedepressivesymptoms,posttraumaticstressdisorder,substanceabuse,andsuicidality(Campbell,1998;Warshaw,1998)Themostgrimconsequenceofdomesticviolenceisdeath;themajorityofwomenwhoarekilledintheUnitedStatesarekilledbyacurrentorformerintimatepartner(Campbell,1998)

Childhoodabuse,likepartnerabuse,isasignificanthealthissueacrosstheglobe

ChildAbuse

Childhoodabuse,likepartnerabuse,isasignificanthealthissueacrosstheglobeChildhoodabusemaybephysical,sexual,orpsychologicalinnature,ormayinvolvepsychologicalorphysicalneglectDefinitionsofchildhoodabuseandmaltreatmentvarywidelyLegaldefinitionsofchildhoodabuse,forexample,differfromstatetostateWhileallstatestatutesacknowledgethatphysicalabuseincludesnon-accidentalphysicalinjurythatresultsinharmorsubstantialriskofharm,somestatutesspecifythetypesofacts(eg,strikingwithanobject)orovertconsequences(eg,visiblebruises)thatconstitutephysicalabuse(Barnettetal,1997)Considerabledisagreementexistsbothamongthepublicandchilddevelopmentprofessionalsastowhatseparates"normal"corporalpunishment(eg,spanking)fromabuseSpanking,paddling,andslappingchildrenasaformofdisciplineisacommonpracticeintheUnitedStatesandsuchbehaviorsaretypicallynotlabeledasabusivebymostadultsOntheotherhand,someexpertshavearguedthatspankingisalwaysharmfulbecauseitlegitimizesviolenceandmayengenderotherformsofinterpersonalaggression(eg,siblingabuse,violenceoutsidethehome)(Straus,199)AsKolko(1996)argued,"Thetaskofdeterminingwhenparentalbehaviorsareexcessive,unwarranted,dangerous,andultimatelyabuseremainsacomplexone"(p22)

Definitionsofchildhoodsexualabusearedependentuponhistorical,cultural,andsocialcontextsandvarywidelyEmotionalabuseandchildneglectareperhapsthemostprevalentformsofchildhoodmaltreatment,andthemostdifficulttodefineBernsteinandFink(1998)haveidentifiedsomecommondefinitionsofchildabuseandneglectfoundinthechildhoodtraumaliterature:

Emotionalabusereferstoverbalassaultsonachild'ssenseofworthorwell-being,oranyhumiliating,demeaning,orthreateningbehaviordirectedtowardachildbyanolderpersonPhysicalabusereferstobodilyassaultsonachildbyanolderpersonthatposeariskof,orresultin,injurySexualabusereferstosexualcontactorconductbetweenachildandolderperson;explicitcoercionisafrequentbutnotessentialfeatureoftheseexperiencesEmotionalneglectreferstothefailureofcaretakerstoprovideachild'sbasicpsychologicalandemotionalneeds,suchaslove,encouragement,belonging,andsupportPhysicalneglectreferstofailureofcaregiverstoprovideachild'sbasicneeds,includingfood,shelter,safety,andsupervision(p2)

Scope

TheThirdNationalIncidenceStudyofChildAbuseandNeglect(NIS-3),conductedbytheNationalCenteronChildAbuseandNeglect,wasmandatedbyCongresstoprovideofficialestimatesofthesephenomenonintheUnitedStatesTheNIS-3followstheNIS-1,publishedin1981,andtheNIS-2,publishedin1986ThefindingsoftheNIS-3arebasedonanationallyrepresentativesampleofover5,600professionalsin82agenciesin2counties,andreflectthenumberofabuseandneglectcasesinvestigatedbychildprotectiveservicesorservedbycommunityagenciesDatawerecollectedin1993andcomparedtodatacollectedintheNIS-2surveyTheNIS-3usedtwostandardsChildrenwhohadalreadyexperiencedharmfromabuseorneglectwereconsideredabusedbytheHarmStandard;childrenwhoexperiencedabuseorneglectthatputthematriskforharmwereconsideredabusedbyEndangermentStandardUsingtheHarmStandard,surveyfindingssuggestthatin1993,1,553,800childrenwereabusedorneglected;thisestimateraisesto2,815,600undertheEndangermentStandardOutlinedinTable1arethenumberofchildrenestimatedtohavebeensexuallyorphysicallyabusedandphysicallyoremotionallyneglectedTheauthorsofthesurveyconcluded,"ThefindingsoftheThirdNationalIncidenceStudyofChildAbuseandNeglect(NIS-3)showasharpincreaseinthescopeoftheproblem,whethermaltreatmentisdefinedusingtheHarmStandardortheEndangermentStandard"(Sedlak&Broadhurst,1996,p7)

Table1

EstimatedincidenceofchildabuseintheUSin1993fromtheThirdNationalIncidenceStudyofChildAbuseandNeglect(Sedlak&Broadhurst,1996)

HarmStandardEndangermentStandard

Sexuallyabused

OfficialestimatessuchasthosederivedfromtheNIS-3surveyarebasedononlythosechildrenwhocometotheattentionofauthoritiesorhelpingprofessionalsTheactualincidenceofabuseandneglectofchildrenintheUSislikelytobemuchhigherParticipantsintheNationalViolenceAgainstWomenSurvey,forexample,wereaskedaseriesofbehaviorallyspecificquestionsaboutarangeofphysicalassaultscommittedbyadultcaretakersMorethanhalfoftherespondentshadexperiencedatleastonephysicalassaultbyacaretaker(Tjaden&Thoennes,2000a)InanationalUStelephonesurveyof2,626adults,27%ofthewomenand16%ofthemenreportedexperiencingsexualabuseduringtheirchildhood(Finkelhor,Hotaling,Lewis,&Smith,1990)

Throughouthistory,parentsandothercaretakershavemaltreatedchildren

History

Throughouthistory,parentsandothercaretakershavemaltreatedchildrenManysocietiespracticeinfanticideandtheabandonmentofunwantedchildrenIndustrializedsocietieshaveusedchildrenfordangerousandexhaustingwork(Barnettetal,1997)Girlsaroundtheworldareespeciallyatriskforsexualabuse,childmarriage,childprostitutionandpornography,andfemalegenitalmutilation(Kendall-Tackett,2001)

IntheUS,childrenhavehistoricallybeenconsideredpropertyoftheirparentsandwithoutlegalrightsIn187,thefirstUSchildabusecasewastriedinNewYork;itresultedinaconvictionofawomanforassaultandbatteryonher8year-oldstepdaughter,MaryEllen(Barnettetal,1997)MaryEllenhadbeenbeatendaily,starved,andprohibitedfromleavingthehouseThiscaseattractedconsiderablepublicattentionandledtothefoundingoftheSocietyforthePreventionofCrueltytoChildren(SPCC)

Intheearly1900s,statelegislaturesbegantoenactstatutescriminalizingtheabuseandneglectofchildrenandprovidingprotectivemeasuresformistreatedchildrenBetween1899and1920,almostallstatesintheUnitedStatesinstitutedstatewidejuvenilecourtsystems(Bulkley,Feller,Stern,&Roe,1996)Inthe1900s,severalchildprotectiveorganizationswerefounded,includingtheNationalCommitteetoPreventChildAbuse,theFamilyResourceCoalition,theChildren'sDefenseFund,theNationalCenterforMissingandExploitedChildren,andtheChildWelfareLeagueofAmerica(Barnettetal,1997)

In1962,CHenryKempe,apediatricianattheUniversityofColorado,andhiscolleaguesidentifiedthe"batteredchildsyndrome"-aconstellationofphysicalandpsychologicalsymptomsresultingfromphysicalchildabuse(Kempe,Silverman,&Stele,1962)Kempe'sworkresultedinincreasedrecognitionandreportingofchildhoodphysicalabusebyhealthprofessionalsandmobilizedadvocacyforgreatergovernmentinterventionforchildwelfareIn197,CongressenactedtheChildAbusePreventionandTreatmentAct(CAPTA),providingfederalfundsforstatesthatpassedlegislationrequiringthereportingofchildabusebycertainprofessionals(eg,teachers,healthcareprofessionals)ItalsoestablishedtheNationalCenterforChildAbuseandNeglect(Barnettetal,1997)The1980sand1990ssawaproliferationofhealth-systemandcommunity-basedinterventionsforthepreventionandtreatmentofphysicalchildabuse(Barnettetal,1997)

Thethird"discovery"ofchildhoodsexualabuseoccurredduringthe1970swiththeadventofthewomen'smovementAlongwithissuesofrapeandwifebattering,activistsandsurvivorsbroughtchildhoodsexualabuseintopublicawareness

Historically,professionalsandthepublicdidnotconsidersexualabusetobeaprevalentortraumaticexperienceinthelivesofchildrenHerman(1981)identifiedthree"discoveries"ofincestInthefirst"discovery,"Freudinitiallyreportedthatfemalepatientsinpsychoanalysisfrequentlydescribedincestuouschildhoodexperiences,andthattheseexperiencesweretherootcauseofadulthysteriaHelaterrepudiatedthisclaimintheserviceofprotectingthecultureofthepatriarchalfamilyandsuggestedinsteadthatthewomen'sclaimswereincestuousfantasiesratherthanactualchildhoodeventsFollowingthisrepudiation,therealityandprevalenceofchildhoodsexualabusewereagaindeniedInthe190s,incestwas"discovered"againbysocialscientistsconductinglargescalesurveysofsexualpractices,suchastheearlyKinseystudiesDespitethefactthattheprevalenceofchildhoodsexualabusewassubstantiatedinthesestudies,HermansuggestedthattherealityoftheexperiencewasminimizedBecausetheresearcherswereattemptingtoencourageenlightenmentandtoleranceofsexualattitudes,theyfailedtohighlightthevictimizingnatureoftheexperiencesThethird"discovery"ofchildhoodsexualabuseoccurredduringthe1970swiththeadventofthewomen'smovementAlongwithissuesofrapeandwifebattering,activistsandsurvivorsbroughtchildhoodsexualabuseintopublicawarenessInthe1980sand1990s,therewasaproliferationofscholarly,clinical,andself-helpliteratureonthetopic

ThesexualabuseofchildrenalsobegantoreceivelegislativeattentionintheUSinthe1970sIn1978,theProtectionofChildrenAgainstSexualExploitationActwaspassedIn1986,theChildSexualAbuseandPornographyActmadeitafederalcrimetosexuallyexploitchildrenortopermitachildtoengageinpornography(Barnettetal,1997)

HealthConsequences

Childabusecanhavesignificantpsychologicalandphysicalconsequencesforchildren,aswellaslong-termeffectsthatmayextendintoadulthoodBarnettandcolleagues(1997)identifiedthemostfrequentlyreportedeffectsofphysicalabuseonchildrenPhysicalconsequencesmayincludebruises;head,chest,andabdominalinjuries;burnsandfracturesAbusedchildrenoftenexhibitanumberofcognitivedifficulties,includingdeficitsinverbal,reading,math,andperceptual-motorskills;poorschoolachievement;andimpairedmemoryBehavioralproblems,suchasaggression,noncompliance,andantisocialbehaviors,havealsobeenassociatedwithabuse,ashaveavarietyofemotionaldifficulties,includingdepression,lowself-esteem,andincreaseddailystressLong-termeffectsinadultsmayincludecriminal/violentbehavior(foradultmales),substanceabuse,andavarietyofsocialandemotionalproblems,includingsuicidality,anxiety,hostility,dissociation,andinterpersonaldifficultiesExpertsstress,however,thatphysicalchildabusedoesnotaffectindividualsinconsistentandpredictablewaysThenegativeeffects,infact,canbemitigatedbyanumberoffactors,especiallybythepresenceofsupportiveadultsinthechild'slife(Barnettetal,1997)

Barnettandcolleagues(1997)havesummarizedthemostfrequentedsubstantiatedeffectsofchildsexualabuseaswellPhysicalconsequencesofchildsexualabuseoftenincludegenitalbruising,bleeding,pain,anditching;enuresis;encopresis;andavarietyofstress-relatedsymptoms,includingsleepandeatingdisturbances,stomachaches,andheadachesShort-termeffectsofchildsexualabuseincludeemotionalproblems,suchasanxiety,depression,aggression,andlowself-esteem,aswellasavarietyofbehavioralandlearningdifficultiesLong-termeffectsexhibitedbyadultsurvivorsofchildsexualabuseincludeemotionaldifficulties,suchasdepression,anxiety,andposttraumaticstresssymptoms;interpersonalandsexualproblems;andcertainbehaviorproblems,suchaseatingandsubstanceabusedisordersAswithphysicalabuse,individualresponsestochildsexualabusearehighlyindividualizedandcanbemediatedbyanumberoffactors,includingthevictim'ssubjectiveperceptionoftheeventsandavailablesocialsupport(Barnettetal,1997)

AmyriadofeffectshavealsobeenassociatedwithchildhoodneglectChildhoodneglectmayresultinsocialdifficulties,includingimpairmentofparent-childinteractionsandproblematicpeerinteractions;intellectualdeficits;andavarietyofemotionalandbehaviorproblems,includinglowself-esteem,ineffectivecoping,aggression,andnegativeaffectThephysicalconsequencesofchildneglectincludefailuretothriveanddeathTheeffectsofpsychologicalmaltreatmenthavenotbeenstudiedextensively,butseemtoincludeavarietyofnegativeeffects,includingdifficultiesininterpersonaladjustment,intellectualdeficits,andaffective-behavioralproblems(Barnettetal,1997)

Expertssuggestthatdomesticelderabuseisperhapsthemostunderreportedcrime

ElderAbuse

TheUSAdministrationonAgingreportsthatthereare3millionAmericansovertheageof60,and3millionwhoare85orolderDuetoimprovedhealthandstandardsofliving,itispredictedthatbytheyear2030,morethan85millionAmericanswillbeover60andmorethan8millionwillbeovertheageof85(AdministrationonAging,2001)Whileotherissuesaffectingtheelderly,suchasretirementsecurityandaffordablelong-termcare,havereceivednationalattention,theabuseandneglectoftheelderlyhashistoricallybeenignored(NationalCenteronElderAbuse,2001)Elderabusehastraditionallybeenassociatedwithstreetcrimes,abuseinnursinghomes,andfinancialfraud(Quinn&Tomita,1997)Onlyrecentlyhaselderabusebyfamilymembersandintimatesattractedscholarlyattention,publicoutrage,andpublicfundingforpreventionandeducation

ExpertssuggestthatdomesticelderabuseisperhapsthemostunderreportedcrimeOlderadultsmaybeespeciallyreluctanttoreportabusebecausetheyareashamedtoadmitthattheirspouseorchildrenhavemistreatedthem,fearretaliation,ordreadbeinginstitutionalizediftheyareremovedfromthecareoftheabuser(Payne,2000,Quinn&Tomita,1997)Inaddition,cognitiveandphysicalimpairmentsmaymakeitimpossibleforsomeelderlyindividualstoreporttheirabuseUnlikechildrenwhomustattendschool,abusedeldersmayremainisolatedintheirhomes

ElderabusehasbeenparticularlydifficulttodefineThereisconsiderabledisagreementoverwhatconstitutesabuseandtheageatwhichonebecomeselderlySomeexpertsbelievethetermelderabuseshouldbelimitedtophysicalorpsychologicalabuseofimpairedanddependentseniors;othersbelievethatfailuretoprovideappropriatecarealsoconstitutesabuseTheNationalCenteronElderAbuse(2001)definesdomesticelderabuseas"anyofseveralformsofmaltreatmentofanolderpersonbysomeonewhohasaspecialrelationwiththeelder(eg,aspouse,asibling,achild,afriend,oracaregiverintheolderperson'shomeorinthehomeofthecaregiver)"(p1)Elderabuseincludesphysicalabuse,sexualabuse,emotionalorpsychologicalabuse,neglect,abandonment,andfinancialormaterialexploitationAswithchildabuse,legaldefinitionsofelderabusevaryfromstatetostate

Scope

TheNationalElderAbuseIncidenceStudy(NEAIS),conductedbytheNationalCenteronElderAbuse,collecteddataondomesticelderabuse,neglect,andself-neglectthroughanationallyrepresentativesampleof20countiesin15states(NationalCenteronElderAbuse,1998)DatawerecollectedfromlocalAdultProtectiveServicesagenciesandfromprofessionalsincommunityagencieswhohadfrequentcontactwiththeelderlyThemethodologywasdesignedtobeconsistentwiththeNationalIncidenceStudiesconductedbytheNationalCenteronChildAbuseandNeglectBasedontheNEAISfindingsandUSCensusdata,itisestimatedthatatotalof9,92personsaged60andoverexperiencedabuseand/orneglectindomesticsettingsin199670,92ofthesecases(16%)werereportedtoandsubstantiatedbyAPSagencies;378,982(8%)werenotTheresearchersalsofoundthatfemalesareabusedmorefrequentlythanmales,andthateldersover80areatthegreatestriskforabuseandneglectIn90%oftheincidentsofelderabuseandneglectbyaknownperpetrator,theperpetratorisafamilymember;two-thirdsoftheperpetratorsareadultchildrenorspouses

PillemerandFinkelhor(1988)conductedalargescale,randomsampletelephonesurveyofelderabuseandneglectTheyinterviewed2,020Bostonarearesidentsovertheageof65andfoundthat32%(N=63)oftherespondentsreportedbeingmaltreatedFortyrespondents(2%)hadexperiencedphysicalabuse,26(11%)chronicverbalaggression,and7(0%)neglectThirty-fiveoftheperpetratorswerespouses,10weresons,5weredaughters,and11wereotherpersons(eg,grandchildren,siblings)Onthebasisofthesesurveyfindings,theauthorsestimatethatonly1in1casesofelderabuseisreportedtotheauthorities

History

Elderabusefirstcametopublicattentioninthe1960swhenitwasdiscussedinBritishmedicaljournalsunderthemisguidedlabelof"grannybashing"In1979,TheBatteredElderSyndromewaspublishedbyBlockandSinnot(1979),bringingtheproblemofelderabusetotheattentionofhealthprofessionalsandhumanservicescholars

Inthelate1960s,theUSDepartmentofSocialandRehabilitationServicesbeganfundingNationalProtectiveServicesThefirstcongressionalhearingonelderabusewasheldin1979bytheHouseSelectCommitteeonAgingIn1981,theNationalCenterforAdultAbusewasestablishedBy1982,everystatedevelopedanadultprotectionprogramand2stateshadadoptedamandatoryelderabusereportinglaw(Payne,2000)

In1987,amendmentstotheOlderAmericansAct(OAA)mandatedthatstatesprovideoutreachservicestoidentifyelderabusecases,deviseprocedurestoprocesselderabusereports,andconductpubliceducationTitleVII,asubsequentamendmenttotheOAA,includedprovisionsforlongtermcareombudsmen,legalassistance,andservicestopreventabuseThroughTitleIVoftheOAA,theAdministrationonAging(AoA)providedfundingforresearchandservicedeliveryprojectsTheAoAalsofundedanationalresourcecenterandanationalsurveyontheincidenceofelderabuse,neglect,andexploitation(Nerenberg,1997)Severalnationaladvocacygroups,suchastheAmericanAssociationofRetiredPersons,theOlderWoman'sLeague,andtheNationalOrganizationofWomen,haveheldforums,assembledcommittees,andorganizedcongressionalhearingstoaddresstheproblemofelderabuseRecently,health-caresystemandcommunity-basedservicesforabusedandneglectedeldershavebeguntobedeveloped(Barnettetal,1997;Vinton,2001)

HealthConsequences

Likeotherformsofdomesticviolence,elderabuseisassociatedwithamyriadofphysicalconsequencesQuinnandTomita(1997)listedanumberofphysicaleffectsthatareindicatorsofelderabuse,includingscratches,cuts,andbruises;sprainsanddislocations;pressuresores,fractures,anddetachedretinasSignsandsymptomsofpossiblesexualabuseincludegenitalorurinaryirritation,injuryorscarring,andintensefearinreactiontoaninvasivepelvicprocedureSignsandsymptomsofpossiblephysicalneglectincludepoorhygiene(bodyodor,mattedhair,unexplainedrashes),hypothermia,untreatedsores,failuretothrive,malnutritionanddehydrationThepsychologicalconsequencesofelderabusehavenotbeensystematicallyresearched

Summary

Despitethefactthatintimatepartnerabuse,childabuse,andelderabusehavecapturedtheattentionofthepublic,socialscienceresearchers,healthcareprofessionals,andpolicymakersworldwide,domesticviolencecontinuestobeaprevalentproblemthatbringssufferingtomillionsandenormouscoststoallsocietiesMahoneyandcolleagues(2001),forexample,argue:

Evenafter25yearsofresearchandadvocacy,intimateviolenceagainstwomenremainsatepidemicproportions,affectingwomenofallagegroupsandallwalksoflife;frompreteengirlstoelderwomen,andwomenofallraces,cultures,sexualorientations,andphysicalabilities(p13)

Despitethefactthatintimatepartnerabuse,childabuse,andelderabusehavecapturedtheattentionofthepublic,socialscienceresearchers,healthcareprofessionals,andpolicymakersworldwide,domesticviolencecontinuestobeaprevalentproblemthatbringssufferingtomillionsandenormouscoststoallsocieties

Nursesandotherhealthcareprofessionalshaverespondedtotheproblemofdomesticviolencebyengaginginincreasinglysophisticatedresearch,designingpreventionandinterventionprograms,andadvocatingforsocialchangeWhilewecelebratethestridesmadeintacklingtheproblemofdomesticviolence,wemustaskwhy,despitesuchconcertedeffortstoaddresstheproblem,domesticviolenceremainsa"plagueinourland"(AmericanAcademyofNursing,1995)

Conclusion

FuturedirectionsfornursescommittedtocombatingdomesticviolencemustoccuronseverallevelsDomesticviolenceisrootedincomplexsociologicalandeconomicfactorsincludingpoverty,sexism,racism,ageism,substanceabuse,familybreakdown,violenceinthemediaandthereadyavailabilityofhandgunsNursesmustadvocateforpolicythatenhanceseconomicopportunitiesandtheredistributionofpowerinoursociety,aswellassupportstateandnationallegislationthatwillfunddomesticviolenceprograms,preventinsurancediscriminationagainstvictimsofdomesticviolence,enhanceimmigrationprotectionsforabusedwomen,ensuretherightsofwomenandchildrenaffectedbywelfarereform,andenhanceprotectionsforolderanddisabledwomenwhoareabusedNurseshavebecomeincreasinglyvocalinsupportoflegislationforhandguncontrolandtheabolishingofdangerousammunition

Onthepracticelevel,nursesinallsettingsmustconsiderroutinescreeningforabuseasastandardofcareWhileuniversalhealthcarescreeningfordomesticviolenceisrecommendedbymosthealthcareorganizations,itismostsuccessfullyimplementedinfacilitiesthathaveaformalinstitution-widecommitmenttothepracticeandcomprehensiveprotocolsthatoutlineintervention,aswellasassessment,strategiesWithinputfromstakeholders,nursesshouldcontinuetosupport,design,andevaluatepreventionandinterventionprogramsthataremulti-disciplinary,innovative,andculturallyspecificCoordinatedresponseprograms,thatarecollaborativecommunity-wideendeavorsinvolvingmultipleagencieschargedwithdomesticviolencepreventionandintervention,seemtoholdthemostpromiseAschildabuseis"thegatewaytomanyothersocialandmaladaptiveproblems"(Thomas,1995,p60),nursesandotherhealthcareprofessionalsshouldbecomeinvolvedincommunity-basedfamilysupportinitiatives,familyskillstrainingprograms,andfamilypreservationservicesSchool-basedprogramsthatidentifyandintervenewithchildrenatriskandthatteachskill-buildingandconflictresolutionskillsarealsoessential

Severalexpertshavesuggestedthatdomesticviolenceserviceshavebeenineffectivebecausetheyarenotculturallyspecific(Koss&Hoffman,2000;Thomas,1995)Programsoftendonotprovideculturallycompetentcounselors,usethetargetlanguageofthegroupsserved,orrespectthetraditionalhealingpracticesofthecommunity(Koss&Hoffman,2000)NurseshavebeguntodescribeculturallyspecificclinicalinterventionsForexample,informationisavailableonprovidinghealthcareforbatteredwomenwhoareAfricanAmerican(Campbell&Gary,1998),NativeAmerican(Bohn,1998),andHispanic(Torres,1998)Thespecialneedsofimmigrantwomen(DasDasgupta,1998),migrantfarmworkerwomen(Rodriguez,1999),ruralwomen(Fishwick,1998),andlesbianwomen(Renzetti,1998)havealsobeenaddressedFuturedirectionsmustinvolveutilizingsuchinformationinpracticesettingsandexpandingourknowledgebaserelatedtotheneedsofethnicgroupsandothermarginalizedpopulations

Finally,nursesmustcareforthemselvesNursesandotherprofessionalswhohaveexperienceddomesticviolencemustbesupportedintheireffortstofindunderstanding,safety,peace,andhealingintheirownlives

Author

ClaireBurkeDraucker,RN,PhD,CS
E-mail-cdraucke@kentedu

ClaireBurkeDraucker,RN,PhD,CSisaProfessorandDirectoroftheGraduatePrograminPsychiatricMentalHealthNursingintheCollegeofNursingatKentStateUniversitySheisalicensedpsychologistintheStateofOhioandaCertifiedClinicalSpecialistinPsychiatricMentalHealthNursingDrDrauckerhasconductedstudiesonearlyfamilyexperiencesandlatervictimizationinthelivesofwomen,thehealingprocessesofwomenandmenwhoweresexuallyabusedaschildren,andwomen'sresponsestosexualviolencebymaleintimatesSheistheauthorofCounselingAdultSurvivorsofChildhoodSexualAbuse(Sage)

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