VICTIMS AND VICTIMIZERS
Betty Jane Kohal
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Identify the various types of abuse
2. Discuss the historical perspectives and epidemiology related to abuse
3. Explain the psychodynamics influencing the victims, as well as the abusers, across the life span
4. Describe the signs and symptoms indicative of abuse and neglect, including the long-term impact of abuse and neglect
5. Describe the models used to explain abuse, including the cycle of violence wheel and the power and control wheel
6. Identify possible barriers faced by the nurse during the assessment process, especially those related to emotional responses that may be experienced when working with victims of abuse as well as with the abusers
7. Describe the legal and ethical responsibilities of the nurse in reporting suspected abuse or neglect
Abusive head trauma
Intimate partner violence
Shaken baby syndrome
Although definitions may vary, the Centers for Disease Control and Prevention (CDC) has made efforts to standardize definitions and currently refers to ABUSE as acts of commission or omission that result in harm, potential for harm, or threat of harm (Saul et al., 2014). Abusive behavior is used to gain or maintain power and control over another person and is the hallmark of DOMESTIC VIOLENCE. Domestic violence can be defined as:
Causing or attempting to cause physical or mental harm to a family or household member
Placing a family or household member in fear of physical or mental harm
Causing or attempting to cause a family or household member to engage in involuntary sexual activity by force, threat of force, or duress
Engaging in activity toward a family or household member that would cause a reasonable person to feel terrorized, frightened, intimidated, threatened, harassed, or molested (Child Welfare Information Gateway, 2013, p. 1).
Violence among spouses or domestic partners is referred to as INTIMATE PARTNER VIOLENCE and is included under the umbrella term of domestic violence. Violence is demonstrated through physical, sexual, economic, or psychological abuse, or a combination of methods. The abuse is used to dominate the person. The control can be manifested directly through use of force, or less directly through manipulation, humiliation, or guilt. Even threats can be used as a way to control others and are considered part of the pattern of abuse.
This chapter focuses on abuse and violence across the life span. It describes the types of abuse and provides an overview of the historical aspects and epidemiology related to abuse and violence. The chapter discusses the etiology related to abuse across the life span and describes the major models used to explain this behavior. The chapter concludes with a discussion of the nursing responsibilities from an interpersonal perspective when caring for victims of abuse and their victimizers.
Abuse reflects a means for exerting power and control over another person.
TYPES OF ABUSE
Abuse can come in many forms. It can be physical, emotional, sexual, or economic. Frequently, the abuser will use more than one method to achieve his or her goal of power and domination. The abuser may begin by using verbal criticism or emotional abuse and gradually move to physical abuse. The physical abuse may also begin with less injurious acts, such as slapping or pushing, and move on to more serious injuries, including infliction of fatal injuries.
Physical abuse involves an act of aggressive behavior that results in bodily injury, pain, or impairment to another. These actions or behaviors include hitting, BATTERING (striking someone repeatedly with violent blows), slapping, kicking, pushing, choking, pinching, hair pulling, or any other action that can cause bodily harm. Although it may involve use of an object or weapon, this is not required for physical abuse. It can also entail inflicting burn injuries such as using cigarettes or caustic chemicals. Typically, the physical abuse will become a pattern of interactions between the abuser and the victim, and the severity will increase over time.
Physical NEGLECT is another type of physical abuse. However, it is considered a nonviolent form of physical abuse. It involves withholding necessities from the victim, such as denying adequate food, clothing, or medical care and attention.
Sexual abuse is also used as a way of gaining control over the victim. It can include any type of sexual activity inflicted on a person without his or her consent. Sexual abuse encompasses forcible intercourse, sadistic sexual acts against the victim aimed at causing humiliation, or other forms of sexual assault or molestation including inappropriate touching.
Emotional or Psychological Abuse
Emotional or psychological abuse involves verbal or nonverbal behaviors that are intended to demean or belittle a person, or cause anguish or distress. Examples of emotional or psychological abuse include insults or constant criticism directed at the person as a way of diminishing his or her self-esteem and self-worth. It can also include threats, intimidation, or harassment that the abuser uses to control the victim. For example, in a same-sex relationship, emotional abuse would be threatening to expose the other’s sexual orientation if that fact is hidden. Isolating a victim from his or her family or friends is another way an abuse can inflict emotional distress. Although emotional or psychological abuse does not usually involve physical violence on the part of the abuser, it may involve violence directed at inanimate objects or pets as a way of demonstrating power or dominance and invoking fear. The abuser may also threaten to harm the victim or someone the victim cares for as a way of exerting power without ever actually committing a violent act. Finally, the abuser may blame the victim for the consequences of the abuse, thereby causing guilt or shame and leaving the victim feeling responsible for the situation. Emotional and psychological abuse are extremely effective in reducing the victim’s confidence and sense of autonomy, as well as enhancing the power and control of the abuser.
Economic abuse is another method of gaining authority or dominance over someone. Economic abuse is a tactic used to control a victim’s finances, thereby preventing the victim from leaving the relationship. Sometimes, the abuser will not permit the victim to work or to maintain control of his or her earnings, thus ensuring dependency on the abuser. The abuser may also interfere with, or prevent, the victim from pursing an education, getting job training, or establishing his or her own credit. Sometimes, the abuser will take actions that jeopardize the victim’s employment or credit status, causing him or her to lose a job or suffer financial losses. Lack of income is a common reason victims cite for staying in abusive relationships (Stylianou, Postmus, & McMahon, 2013). Confidence crimes, fraud, and scams, such as telemarketing scams for financial gain, are examples of economic or financial abuse found in the elderly population (James, Boyle, & Bennett, 2014). Elderly with limited financial and health literacy are at particular risk for falling prey to con artists (James et al., 2014). Financial exploitation is now considered the most common, yet least detected or reported form of elder abuse (Sullivan-Wilson & Jackson, 2014).
The four types of abuse are physical, emotional or psychological, sexual, and economic (or financial) abuse.
In many cultures throughout history, the value and rights of women and children were limited or nonexistent. During Roman times, the “paterfamilias,” or male head of the household, had absolute power over his household and children. If his children angered him, he had the legal right to disown them, sell them into slavery, or even kill them. The head of the household also had power over his wife and her property and possessions (Fustel des Coulanges & Numa Denis, 1980). This was also true in many Asian cultures, where women were dominated by the male head of the family and had limited legal rights (Jejeebhoy, Santhya, & Acharya, 2014). In North America during Colonial times, the courts typically followed English common law. These laws stipulated that a married woman’s property and possessions became her husband’s after her marriage (Kerber & De Hart, 1995). Children were often viewed as part of this property and parents could do whatever they wished to their children.
The use of corporal punishment against children can be traced back to biblical times. The St. James version of the Bible states, “Spare the rod, spoil the child.” This particular biblical passage has given many persons the “right” to physically hit the child.
American women in the 21st century are no longer legally limited by patriarchal views. However, many personal, religious, and cultural beliefs still influence the role of women and children and how they are treated in the home. Frequently, they are relegated to subservient or submissive positions. Over the years, women have frequently been referred to as the “weaker” sex, being considered physically and intellectually inferior to men.
These continuing attitudes have had an impact on the behaviors of some men, leading them to believe that they have the right to control their spouse or partner as well as to use corporal punishment with their children. In addition, historically, domestic violence has not been treated the same way other violent crimes were treated by law enforcement. Many people, including law enforcement personnel, viewed spousal abuse as a private matter. Until the 1950s, written police policies in many jurisdictions actually directed officers to “recognize the sanctity of the home” and to end the disturbance “without making an arrest” (Finesmith, 1983). A husband could even have sex with his wife against her will without being charged with rape.
Over the years, greater understanding of domestic violence created more pressure on law enforcement to change. Yet, the violence was still not considered criminal behavior. The abusers were seldom arrested and were rarely tried in court (Finesmith, 1983). It was not until 1994 that increasing public pressure to recognize domestic violence as a crime rather than a family problem resulted in the passage of the federal Violence Against Women Act (VAWA, 2013). This Act, and the 1996 additions to the Act, recognizes that domestic violence is a national crime. In 1994 and 1996, Congress also passed changes to the Gun Control Act making it a federal crime in certain situations for domestic abusers to possess guns.
Domestic violence is not just a female issue. Men can also be the victims of domestic violence. Estimating prevalence is difficult, however, because the literature presents conflicting information related to the numbers of events reported (Nowinski & Bowen, 2012). The conflicting information reported may be due in part to gender stereotypes that lead males to feel ashamed of being subjected to abuse or to fear that no one will believe them because of society’s view of men as more powerful (Domesticviolence.org.handbook). It is clear that violence against men is a problem that needs to be addressed. Intimate partner violence (IPV) also impacts nonheterosexual couples. Reported rates of abuse are comparable to those of heterosexual couples (Hellemans, Loeys, Buysse, Dewaele, & Smet, 2015).
Domestic abuse historically was viewed as a family problem. However, increasing public pressure has led to legislation recognizing domestic violence as a crime.
Abuse crosses all races, genders, socioeconomic status, religions, marital status, ages, and cultures. Anyone can be a victim of abuse or a victimizer. Abuse is a pervasive problem in society (Black et al., 2011). Interventions are required at primary as well as secondary and tertiary levels:
Primary interventions focus on efforts to prevent abuse from ever occurring
Secondary interventions focus on identifying risk factors and providing early involvement to reduce negative consequences
Tertiary interventions focus on repairing the consequences of abuse
Determining the best approaches to identification and treatment of victims of abuse has been challenging. A recent Cochrane Review of screening programs to identify victims of violence has determined that screening activities do work in increasing recognition of victims; however, there is no indication that it has led to an increase in referrals to treatment (Taft et al., 2013). There is certainly a need for further evaluation and review to assist in determining the best course of action when working with victims of domestic violence.
Anyone can be the victim of domestic violence. Many victims suffer physical injuries ranging from cuts and bruises to death. However, not all abuse cases involve physical abuse. Domestic abuse can cause serious emotional and psychological harm. The stress that victims feel may also lead to depression and other psychiatric disorders. Some victims even consider and/or commit suicide.
The effects of abuse are far reaching and impact the entire family, not just the designated victim. Abuse leads to increased incidence of health problems, substance abuse, school truancy, and more violence (U.S. CDC, 2014). The Adverse Childhood Experiences (ACE) study conducted in 1998 (Fellitti et al.,1998) is one of the largest investigations ever conducted on the links between childhood maltreatment and later-life health and well-being. The findings suggest that ACEs are major risk factors for the leading causes of illness and death (Larkin, Shields, & Anda, 2012).
Child abuse refers to the physical, emotional, and/or sexual abuse of persons younger than 18 years. Abuse against children occurs most frequently between the ages of 3 and 5 years, a time when a child is most vulnerable and expects to be protected by the parent and/or caregiver. Most children perceive the victimization as their fault and are often told that by the perpetrator.
The most frequently identified abuser of children between the ages of 3 and 5 years is someone the child knows, often the stepfather of the child. Victimized children are told “not to tell” or bad things will happen if they disclose their “secret.” Numerous studies of adults who are survivors of child abuse reveal that they never disclosed their childhood trauma for fear that no one would believe them, or if they did disclose it, their mothers did not believe them. The result of the child not being trusted to have disclosed the truth is a revictimization of the child.
Physical neglect of children is defined as not providing those things children need to survive the elements, nourish their bodies, prevent disease, and treat illness when it occurs, and to educate them so they will be able to perform self-care. Parents neglect their children either as a mechanism to punish them or due to lack of resources or lack of knowledge.
Although reports indicate that more than 1,000 children younger than 15 years die from maltreatment (physical abuse and neglect) every year, this is considered an underestimation of the true number of victims due to the difficulty of case finding and accurate identification of maltreatment (Whitt-Woosley, Sprang, & Gustman, 2014). The risk of death by maltreatment is greatest for infants and very young children (Saul et al., 2014) and frequently involves head trauma or blunt force injury. The most common form of ABUSIVE HEAD TRAUMA is the result of shaking and is often referred to as SHAKEN BABY SYNDROME (March & Cabrera, 2015). For those who sustain nonlethal injuries due to abuse or neglect, the long-term impact of those injuries include an increased likelihood of chronic medical and psychiatric illness, such as cardiac disease, anxiety disorders, and depression (Loc, 2014). Finally, limited focus is placed on the occurrence of emotional abuse without co-occurring physical or sexual abuse or neglect; yet, this form of abuse can also have significant long-term effects including the development of behavioral problems, psychiatric issues, substance use disorders, and future violence (Barlow, MacMillan, Macdonald, Bennett, & Larkin, 2013).
Intimate Partner Violence
Domestic violence remains a leading cause of injury to women between the ages of 15 and 44 years.
Domestic violence involving abuse (i.e., rape, sexual assault, robbery, and aggravated and simple assault) perpetrated by an intimate partner, immediate family member, or other relative accounted for more than one fifth of all nonfatal violent crime against victims during the aggregate period of 2003 to 2012. Violence perpetrated by the intimate partner accounted for the greatest percentage (15%), far in excess of that perpetrated by either immediate family members or other relatives. The majority of violence was committed against females (76%) compared with males (24%), and most acts (77%) occurred at or near the victim’s home. Rates of IPV were greater for those persons who were separated (44.7 per 1,000) or divorced (11.4 per 1,000), compared with those who were never married (4.4 per 1,000), married (1.0 per 1,000), or widowed (0.6 per 1,000; Truman & Morgan, 2014).
Over a lifetime, almost one in four women has been subjected to severe physical violence by an intimate partner, whereas one in seven men has experienced the same. Women have also been the victims of stalking, with one in six experiencing this in their lifetime, compared with 1 in 19 men (Breiding et al., 2011).
Women who have experienced physical or sexual assault by an intimate partner or who have been stalked by any perpetrator in their lifetime were far more likely to experience medical issues such as asthma, diabetes and irritable bowel syndrome, frequent headaches, chronic pain, and sleep difficulties than women who had not experienced these forms of abuse (Black et al., 2011).
In 2011, the Federal Bureau of Investigation (FBI) reported that males in incidents involving a single victim/single offender murdered almost 2,000 females. Of these homicides, where victim-to-offender relationship was ascertained, a male they knew murdered 94% of the victims. In 61% of the cases where the homicide victims knew their offenders, they were the wives or intimate acquaintances of their killers (Bureau of Justice Statistics, 2013). Most often, the victim was killed with a hand gun during the course of an argument (Violence Policy Center, 2013).
It is important to realize that victims of IPV are often subjected to more than one form of abuse, that is, a physically abused victim may also be sexually abused. The victim may also be subjected to abuse after leaving the relationship, through the experience of being stalked. STALKING involves the ongoing pursuit of the victim by the perpetrator, presumably to rekindle the relationship. The pursuit is considered to be stalking if it generates fear in the victim. There is evidence indicating that stalking is more likely to occur if a victim has experienced multiple forms of abuse, even if a restraining order against contact has been enacted (Katz & Rich, 2015).
For the elderly, abuse is often manifested through neglect, which involves failure to provide for the needs of the person, including basic needs of food and shelter as well as medical needs. It also includes physical, emotional, sexual, and financial abuse. Elderly patients with significant physical or cognitive impairment are at greater risk for experiencing abuse (Dong & Simon, 2014). A complicating factor encountered when caring for the elderly patient is self-neglect. Cognitive impairment, psychiatric disorders, and alcohol abuse are predisposing factors for self-neglect. Self-neglect can have a significant impact on a patient’s health and well-being, leading to serious malnutrition and early mortality (Papaioannou, Räihä, & Kivelä, 2012). It is estimated that up to 5 million Americans are affected by ELDER ABUSE each year (Connolly, Brandl, & Breckman, 2014). However, it is felt that for every case of elder abuse, neglect, exploitation, or self-neglect that is reported, five more go unreported (Watson, 2013). (See Chapter 23 for additional information on elder abuse as a factor for mental health problems.)
Anyone can be a victim or perpetrator of abuse. However, reported victims are most often females and reported victimizers are most often males.
Most experts believe that domestic violence is a learned behavior that is more common for individuals who have grown up in violent homes. It can also be reinforced by cultural beliefs that sanction the use of violence such as those that permit the so-called HONOR KILLINGS. Honor killings are based on the belief that women are the property of male relatives and embody the honor of the men to whom they “belong.” The concepts of male status and family status are of particular importance in cultures where “honor killings” occur. If a woman or girl is accused or suspected of engaging in behaviors that could taint male and/or family status, it is the male’s duty to maintain the family honor. The male will kill the alleged offender to maintain the family honor (Kulczycki & Windle, 2011). Honor killings, although generally not officially sanctioned, continue to occur in many countries (Kiener, 2011). One recent study of adolescents in Jordan indicated that a significant number of both male and female adolescents consider that killing a woman who was considered to have dishonored her family was moral and justified (Eisner & Ghuneim, 2013).
The common belief surrounding abuse is that it is a learned behavior, occurring most commonly in households where individuals have grown up being exposed to violence.
Adults who abuse children are often adult survivors of child abuse themselves. Commonly, adult survivors of abuse report never having dealt with the emotions surrounding their trauma. In many instances, the trauma has been repressed so they have no conscious awareness of the experience. Behavioral indicators of unresolved childhood trauma include self-destructive behavior, failure to complete tasks, unsatisfying intimate relationships, as well as being abusive to their own children. Box 24-1 summarizes the types of abuse seen in children.
Intimate Partner Violence
IPV involves abuse by a current or former intimate partner or spouse. This type of violence can occur among heterosexual or same-sex couples. Current theories regarding domestic violence and IPV agree that it is not specifically caused by illness, genetics, substance abuse, anger, stress, or the history or behavior of the victim, although these factors may increase the risk of domestic violence (Breiding et al., 2011).
BOX 24-1: ABUSE IN CHILDREN
CHILD PHYSICAL ABUSE
• Bringing physical harm to a child with the intent of having power and control over the child
• Examples: Fractures, contusions, lacerations, concussions, burn marks from ropes and straps, and bite marks.
• Both physical and emotional
• Examples: Not providing appropriate nourishment; not taking the child to a health care provider when ill; not ensuring the child attends school or, if truant, doing nothing to facilitate the child’s attendance; not providing weather-appropriate clothing; leaving the child alone without a caregiver when the child is less than the age of 12 years.
• Occurs every time physical abuse is experienced
• Examples: Failing to provide the child with love and affection; not telling the child he or she is loved or cared for; and not providing appropriate touch
• Other examples: Talking to the child in a threatening manner; calling the child demeaning names; exposing the child to profanity.
CHILD SEXUAL ABUSE
• Inappropriate touching of the genitals/breasts of a person less than the age of 12 years
• STATUTORY RAPE, that is, sexual intercourse with an adolescent between the ages of 13 and 18 years
• Examples: Inserting things into the vagina or penile penetration of the vagina; having oral or anal sex; having a child perform masturbation either on himself or herself or the perpetrator; exposing children to sexually explicit pictures or sexual acts.
Additional risk factors include:
Seeing or being a victim of violence as a child
Unemployment or work-related stressors
Some cases of elder abuse involve IPV, but many cases also involve abuse by an adult child of the victim. Abusers may be dependent on their victims for financial assistance due to personal issues, substance abuse issues, or psychiatric problems. The risk for the victim is higher when the abuser lives with the victim. Other factors that have been postulated to contribute to elder abuse include caregiver strain, the relationship between the caregiver and the patient, and the type of dependency experienced (the more difficult it is to provide care for the patients due to their disturbed behavior, dementia, character disorder, or the extensive nature of their care needs, the higher the risk of abuse). Determining risk factors for abuse, for example, cognitive impairment, physical impairment, social isolation, and depressive symptoms, may allow for early identification of elderly patients at risk (Dong & Simon, 2014).
PATTERNS OF VIOLENCE
A number of paradigms have been constructed to help describe the phenomenon of domestic violence. Three of these models are described here.
The Cycle of Violence
The cycle of violence was introduced in 1979 by L. Walker based on research she conducted with battered women. Walker concluded that there were three distinct phases involved in the pattern of domestic abuse. Figure 24-1 illustrates this cycle.
The first phase is referred to as the tension-building phase. During this period, the abuser becomes increasingly hostile and agitated and more and more critical toward the victim. Victims frequently describe feeling as if they are “walking on eggshells” during the period. No matter what they try, they are unable to reduce the tension and appease the abuser. This phase is followed by the acute-battering phase or explosive phase, which involves an actual attack. At first the attack may be only verbal, but it usually progresses to physical violence. The final phase of the cycle is the honeymoon phase or the loving–contrition period. During this phase, the abuser tries to make amends, typically becoming affectionate and solicitous of the victim, often promising that the violence will “never happen again” (Walker, 2009). Table 24-1 summarizes the behaviors of this cycle.
The cycle of violence consists of three phases: tension-building phase, acute-battering (or explosive) phase, and the honeymoon (or loving–contrition) phase.
Certain advocacy groups have raised concern that Walker’s model may reinforce the concept of “blaming the victim” because in this model, had the victim been able to alleviate the tension, the event would not have happened. There is also concern that the model implies that the “tension” is precipitated by something that can be misinterpreted as providing an “excuse” for the abuser.
Cycle of Abuse
In 1983, the antiviolence movement in Salem, Oregon, proposed another model for the cycle of domestic violence (Center for Hope and Safety, 1998). This is illustrated in Figure 24-2. The model defines six distinct phases in the cycle.
In the initial phases, the abuser fantasizes and plans the abuse, imagining all the things the victim has done wrongly, and plans how to make the victim pay for these actions. The abuser will then “set up” the scenario to perpetrate the abuse. Again, the abuse may be physical, emotional, economic, or sexual. Once the abusive episode is over, the perpetrator may experience guilt, but it is postulated that the guilt is not guilt due to the harm caused to the victims; rather, the guilt is caused by concerns regarding the consequences of the action. The abuser will become apologetic and solicitous to avoid any repercussions. The abuser will then rationalize the actions and blame the victim for creating the situation that precipitated the violence. The abuser will then return to life as “normal,” as if nothing transpired.