31. Relationship Crimes

CHAPTER 31. Relationship Crimes

Cris Finn



This chapter highlights and explores the various considerations integral to the holistic care of the victim of relationship crimes of violence. This is a summary of the recent knowledge; as such, it is not intended to be a comprehensive review of the literature. It is written to assist forensic nurses, healthcare professionals, and others who come in contact with relationship violence victims. To ensure optimum management of victims of violence, The Joint Commission has advocated some practice guidelines.


Violence against another person is illegal as well as contrary to the moral and ethical standards that guide human behavior. Relationships are nothing short of complicated. Relationships are unions between two individuals or more that are established on mutual agreements that are formal or informal. Relationships can vary based on many external factors; however, the preceding definition is the most widely accepted. Mutual emotional attachments may or may not be obligatory in relationships.

The topics to be explored in this chapter include domestic violence, acquaintance violence, stalking, escort/prostitution violence, violence against men, elder abuse, workplace violence, mentor-teacher student abuse, and crimes against homeless people.


Domestic Violence


Domestic violence (DV) encompasses all acts of violence against persons within the context of family or intimate relationships. Violence in the home has many names: domestic violence, intimate partner violence, spousal abuse, interpersonal violence, and family violence, in addition to battery, partner abuse, or spousal abuse. It is an issue of increasing concern because it has a negative effect on all family members, especially children. Domestic violence occurs in every culture, country, and age group. It affects people from all socioeconomic, educational, and religious backgrounds and takes place in same-sex as well as heterosexual relationships. Women with fewer resources or greater perceived vulnerability, girls, and those experiencing physical or psychiatric disability or living below the poverty line are at even greater risk for domestic violence and lifetime abuse. Children are also affected by domestic violence, even if they do not witness it directly. Although both men and woman can be victims, it is the leading cause of injury to women in the United States, where they are more likely to be assaulted, injured, raped, or killed by a male partner than by any other type of assailant. Statistics indicate that 29% of all violence against women by a single offender is committed by an intimate: a husband, ex-husband, boyfriend, or ex-boyfriend (Centers for Disease Control [CDC], 2008). Accurate information on the extent of domestic violence is difficult to obtain because of extensive underreporting. However, it is estimated that as many as 4 million instances of domestic abuse against women occur annually in the United States (CDC, 2008).



Scope of the problem


According to a National Violence Against Women Survey (2008), 22% of women are physically assaulted by a partner or date during their lifetime, and nearly 5.3 million partner victimizations occur each year among U.S. women ages 18 and older, resulting in 2 million injuries and 1300 deaths. Further findings include the following: nearly 25% of women have been raped or physically assaulted by an intimate partner during their lives; 15.4% of gay men, 11.4% of lesbians, and 7.7% of heterosexual men are assaulted by a date or intimate partner during their lives; and more than 1 million women and 371,000 men are stalked by partners each year (American Medical Association [AMA], 2008). Each year it is estimated that expenses for domestic violence total at least $5 million; businesses forfeit an additional $100 million in lost wages, sick leave, absenteeism, and nonproductive time (Domestic Violence for Health Providers, 1991). It is estimated that only about 10% of all domestic violence incidents are reported. Each year more than 1 million women seek medical treatment for injuries inflicted by their significant other. The Federal Bureau of Investigation (FBI) has reported that approximately one third of all female homicide victims are killed by husbands, ex-husbands, boyfriends, or ex-boyfriends (1992). Between 8% and 11% of pregnant women are abused by their partners (AMA, 2008).

In the mid-1980s, the U.S. attorney general began drawing attention to domestic violence and the act of victimizing an intimate partner. Men are the perpetrators in approximately 90% of all reported domestic assaults, and women are ten times as likely as men to be injured in episodes of domestic abuse. Among female murder victims in the United States, about one third are killed by their partner each year, whereas only 4% of all male victims are killed by their partners (Campbell, 1995).


Risk factors


The risk factors that place women at risk for abuse are as broad and unique as is the population. Simply based on their gender, women are at risk (Stark & Flitcraft, 1996). Abusers use many ways to isolate, intimidate, and control their partners. It starts insidiously and may be difficult to recognize. Early on, the partner seems attentive, generous, and protective in ways that later turn out to be frightening and controlling. Initially the abuse is isolated incidents for which the partner expresses remorse and promises never to do again or rationalizes as being due to stress or caused by something the woman did or did not do.

A number of studies have looked into identifying individuals who are most at risk for domestic violence. The most common feature is an imbalance of power and control. However, neither those who experience domestic violence nor the partners who abuse them fall into distinct categories. They can be of any age, ethnicity, income level, or level of education. The following are examples of situations that are common among people who experience domestic violence. It is important to understand that anyone can be abused.

Some common themes among individuals at risk are as follows:




• Planning to leave or has recently left an abusive relationship


• Previously in an abusive relationship


• Poverty or poor living situations


• Unemployed


• Physical or mental disability


• Recently separated or divorced


• Isolated socially from family and friends


• Abused as a child


• Witnessed domestic violence as a child


• Pregnancy, especially if unplanned


• Younger than 30 years


• Stalked by a partner

Although the abusers also share some common characteristics, it is important to note that abusers choose violence to get what they want in a relationship. Risk factors may point to an increased likelihood of violence in a relationship, but the person is not destined to become violent because of the presence of certain risk factors. Nor is the violence justifiable because it happened while the abuser was in a rage that he or she was powerless to control.

The following factors may indicate an increased likelihood that a person may choose violence:




• Abuses alcohol or drugs


• Witnessed abuse as a child


• Was a victim of abuse as a child


• Abused former partners


• Is unemployed or underemployed


• Abuses pets


Clinical presentations


Domestic violence may lead to both physical and psychological signs and symptoms in the victim. Victims may have obvious physical signs of traumatic injury, but they may also complain of non-injury signs and symptoms, such as chronic abdominal pain, that may seem unrelated to an abusive relationship. Family and friends, even coworkers, may see the following signs and symptoms. These are also signs that forensic nurses and all healthcare providers look for in assessing potential victims of domestic abuse.


Psychological signs and symptoms


Recognizing the signs and symptoms of domestic violence begins by observing the behavior of both the abuser and the person being abused. The abuser may appear overly controlling or coercive, attempting to answer all questions for the victim or isolating him or her from others. This type of behavior may occur in the context of a visit to the healthcare provider where the abuser refuses to let the victim out of his or her sight and attempts to answer all questions for the victim. In stark contrast, the person being abused may appear quiet and passive. He or she may show outward signs of depression such as crying and poor eye contact. Other psychological signs of domestic violence range from anxiety, depression, and chronic fatigue to suicidal tendencies and the battered woman syndrome—a syndrome similar to the posttraumatic stress disorder seen in people threatened with death or serious injury in extremely stressful situations (such as war). Substance abuse is also more common in the person enduring domestic violence than in the general adult population. The abuse of alcohol, prescription drugs, and illicit drugs may occur as a result of the violent relationship rather than being the cause of the violence.


Biomarkers


Domestic violence assault may lead to specific injury types and distributions. These injury types and patterns may result from things other than domestic violence but should raise suspicion of abuse when present. Injury types seen more commonly in domestic-violence injuries than in injuries caused by other means are tympanic membrane (eardrum) rupture; rectal or genital injury; facial scrapes, bruises, cuts, or fractures; neck scrapes or bruises; abdominal cuts or bruises; loose or broken teeth; head scrapes or bruises; body scrapes or bruises; and arm scrapes or bruises.

Physical signs and symptoms of domestic violence that result from traumatic injury may seem similar to injuries resulting from other causes. But some injury types and locations may increase the suspicion of assault violence. The distribution of injuries on the body that typically occurs in the domestic-violence assault may follow certain patterns. Some frequently seen patterns of injury are as follows:




Centrally located injuries. Injury distribution is in a bathing-suit pattern, primarily involving the breasts, body, buttocks, and genitals. These areas are usually covered by clothing, concealing obvious signs of injury. Another central location is the head and neck, which is the site of up to 50% of abusive injuries.


Characteristic domestic violence injuries. These include cigarette burns, bite marks, rope burns, bruises, and welts with the outline of a recognizable weapon (such as a belt buckle).


Bilateral injuries. Injuries involving both sides of the body, usually the arms and legs.


Defensive posture injuries. Injuries to the parts of the body used by the woman to fend off an attack: the small finger side of the forearm or the palms when used to block blows to the head and chest; the bottoms of the feet when used to kick away an assailant; and the back, legs, buttocks, and back of the head when the victim is crouched on the floor.


Injuries inconsistent with the explanation given. The injury type or severity does not fit with the reported cause; the mechanism of injury reported would not produce the signs of injury found on physical examination.


Injuries in various stages of healing. Signs of both recent and old injuries may represent a history of ongoing abuse, and a delay in seeking medical attention for injuries may indicate either the victim’s reluctance to involve doctors or his or her inability to leave home to seek needed care.


Non-injury physical signs and symptoms. Individuals experiencing ongoing abuse and stress in their lives may develop medical complaints as a direct or indirect result. Often the person enduring domestic violence goes to the emergency department or clinic on multiple occasions with no physical examination findings to account for his or her symptoms. Some typical medical complaints may include headache, neck pain, chest pain, heart beating too fast, choking sensations, numbness and tingling, painful sexual intercourse, pelvic pain, urinary tract infection, vaginal pain, HIV/AIDS, and dysmenorrhea resulting from forced and unprotected sex.


Screening and assessment


There are several published, reliable, and valid screening tools used in healthcare settings. Among the best known are the three-question Partner Violence Screen (PVS) (Feldhaus, Koziol-McLain, Amsbury, Norton, Lowenstein, & Abbott, 1997) and the Abuse Assessment Screen (AAS) (Helton, 1986 and McFarlane et al., 1992); versions of varying lengths are available. Early screening, identification, and treatment of domestic violence can help break often serious and deadly cycles of violence. Each time a battered woman presents for care, a window of opportunity is opened. Abuse escalates and increases in severity over time, thus the cycle of violence continues. The key to comprehensive assessments includes insight and knowledge of the various presentations consistent with domestic violence. Persons who present with a history of trauma should be carefully assessed for injuries consistent with the history or the injury. Injuries to the face, head, and trunk are consistent with battering and abuse. Nontrauma-related presentations such as vague somatic complaints, depression, suicide attempts, and gynecological problems may be related to abuse by a partner.

The health provider or forensic nurse must conduct the interview in a private area, which affords the patient the opportunity to disclose the precipitating factors resulting in the symptoms. Emergent and urgent medical needs can be precipitated by trauma and injury, as well as pre- or postpartum complications. Sensitive and direct questions validate and confirm the seriousness of the situation and the availability of help and education. Assessing for domestic violence with a reliable and valid screening tool is now considered a nursing standard of care. With any positive finding of abuse, the forensic nurse should have immediate access to the Danger Assessment and HARASS tools to further explore for risk of domestic homicide.

The evidence reviewed in this chapter suggests that sanctions against partner beating or battering (and some form of sanctuary for women when they were first beaten) are important in keeping levels of violence against women somewhat contained. Experience has shown that the immediate posttrauma period is both the most dangerous time for the woman to leave their home, but it is also the most teachable moment for forensic nurses to help them to make positive changes. Interventions at this point are vital. Nurses, as healthcare professionals (and in some states as mandatory reporters), have ethical, legal, and moral obligations to report abuse to appropriate agencies and to provide understanding; considerate, competent, and supportive nursing interventions that safeguard personal dignity and respect cultural, spiritual, and psychosocial values to the diverse populations seen in their practices. The Emergency Nurses Association position statement on DV and approaching diversity in healthcare addresses this issue for emergency nurses (ENA, www.ena.org, 2009).


Children as victims and witnesses


The risk of child abuse is extremely high in families where domestic violence occurs. In the United States, at least 3.3 million children between the ages of 2 and 18 witness parental violence annually (CDC, 2008). Children of abused women are much more aware of the violence than their parents realize (Nettleton, 2001). Strategies must be considered by the forensic nurse to make a difference in the lives of these vulnerable children through identification, access to services, and coordination for protection.


Acquaintance Violence (Date Rape)


Acquaintance rape, which is also referred to as “date rape,” has been increasingly recognized as a real and relatively common problem within society. Much of the attention that has been focused on this issue has emerged as part of the growing willingness to acknowledge and address issues associated with domestic violence and the rights of women in general since the 1970s. Although the early and mid-1970s saw the emergence of education and mobilization to combat rape, it was not until the early 1980s that acquaintance rape began to assume a more distinct form in the public consciousness. The scholarly research done by psychologist Mary Koss and her colleagues is widely recognized as the primary impetus for raising awareness to a new level.

When people think of rape, they might think of a stranger jumping out of a shadowy place and sexually attacking someone. But it is not only strangers who rape. In fact, about half of all people who are raped know the person who attacked them. Girls and women are most often raped, but boys and men also can be raped. Most friendships, acquaintances, and dates never lead to violence, of course. But, sadly, sometimes it happens. When forced sex occurs between two people who already know each other, it is known as date rape or acquaintance rape. According to Dictionary.com, date rape is “Rape perpetrated by the victim’s social escort.” Wikipedia defines it as “Rape or non-consensual sexual activity between people who are already acquainted, or who know each other socially—friends, acquaintances, people on a date, or even people in an existing romantic relationship—where it is alleged that consent for sexual activity was not given, or was given under duress. In most jurisdictions, there is no legal distinction between rape committed by a stranger, or by an acquaintance, friend or lover.” The term date rape, also called contact rape, acquaintance rape, or sleep rape, refers to nonconsensual sexual activity between people who are already acquainted, whose consent for sexual activity was not given or was given under duress. Date rape and acquaintance rape are forms of sexual assault involving coercive sexual activities perpetrated by an acquaintance of the rape survivor. The perpetrator is almost always a man, and though both men and women can be raped, women are most often the targets of this violence. It is difficult, because of a lack of research on the subject and the tendency for rape survivors not to report attacks, to come up with precise statistics on male survivors. However, men are raped by other men and are also victims of sexual violence. Date and acquaintance rape can happen to or be perpetrated by anyone. Incidences are very high: this form of rape comprises from 50% to 75% of all reported rapes. However, even these figures are not reliable. According to conservative FBI statistics, only 31/2% to 10% of all forms of rape are even reported.


Scope of the problem


According to the National Studies of College Women (National Institutes of Health, 2005), 84% of women who were raped knew their assailants; 57% of rapes occurred on a date; 25% of men surveyed believed that rape was acceptable if the women asks the man out, if the man pays for the date, or the woman goes back to the man’s room after the date; 33% of males surveyed said they would commit rape if they definitely could escape detection; 84% of male students who had committed acts that clearly met the legal definition of rape said what they had done was definitely not rape; 75% of male and 55% of female students in an occurrence of date rape had been drinking or using drugs; only a quarter to a third of women whose sexual assaults met the legal definition of rape considered themselves rape victims; many women do not report or characterize their victimization as a crime for reasons such as embarrassment, because they do not want to define someone who assaulted them as a rapist, or because they do not know the legal definition of rape. Many women blame themselves. Nearly 5% of college women are victimized in any given year, meaning over a four-year period, one fifth to one quarter of a cohort of women may be assaulted. Similar numbers experienced attempted rape. The majority of rapes occur in living quarters: 60% in the victim’s residence, 10% in a fraternity, and 31% in other living quarters. Off-campus victimizations also took place in bars, dance clubs, and work settings. Fifty percent of high school boys and 42% of girls said there were times it was acceptable for a male to hold a female down and physically force her to engage in intercourse.

Even if the two people know each other well, and even if they were intimate or had sex before, no one has the right to force a sexual act on another person against his or her will. Although it involves forced sex, rape is not about sex or passion. Rape has nothing to do with love. Rape is an act of aggression and violence. Some people say those who have been raped were somehow “asking for it” because of the clothes they wore or the way they acted. The person who is raped is not to blame. Rape is always the fault of the rapist. Healthy relationships involve respect, including respect for the feelings of others.


Aspects


Nov 8, 2016 | Posted by in NURSING | Comments Off on 31. Relationship Crimes

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