Kären M. Landenburger is a professor of nursing at the University of Washington, Tacoma. She received her PhD in nursing and her postdoctoral training in women’s health from the University of Washington. Her area of expertise in community/public health nursing is the health and functioning of communities and populations, with an emphasis on community assessment, program planning and evaluation, and community partnerships. She is involved in community action research with communities focusing on public health issues and working on identifying field methods to use in collecting data on communities and populations. Her current research and practice focus on violence against women. She is involved on community and state levels in the education of health professionals about domestic violence as a social issue and about the needs of women who seek care.

Jacquelyn C. Campbell, PhD, RN, FAAN

Jacquelyn C. Campbell is the Anna D. Wolf Chair and Professor in the Johns Hopkins University School of Nursing with a joint appointment in the Bloomberg School of Public Health. She is also the National Program Director of the Robert Wood Johnson Nurse Faculty Scholars Program. Her BSN, MSN, and PhD are from Duke University, Wright State University, and the University of Rochester schools of nursing. She has been conducting advocacy policy work and research in the area of domestic violence since 1980. Dr. Campbell has been the principle investigator on ten major National Institutes of Health, National Institute of Justice, and Centers for Disease Control and Prevention research grants and has published more than 220 articles and seven books on this subject. She is an elected member of the Institute of Medicine and the American Academy of Nursing, is Chair of the Board of Directors Family Violence Defense Fund, and was a member of the congressionally appointed U.S. Department of Defense Task Force on Domestic Violence, as well as a member of the board of directors and the House of Ruth Battered Women’s Shelter.

ADDITIONAL RESOURCES

Website

http://evolve.elsevier.com/Stanhope

• Healthy People 2020

• Answers to Practice Application

The word violence comes from the Latin violare, meaning to violate, injure, or rape. Indeed, violence is a violation, with both emotional and physical effects. Violent crime rates in the United States, including rape, robbery, homicide and assault, have declined by 41% since 1998. Although females were more likely to be victims of sexual assault, men experienced higher levels of stranger victimization in all other violent crimes. Women remain at greater risk in the home with 33% of female homicide victims killed by an intimate partner (USDOJ, 2007, 2009a,b). While rates may be decreasing in adult intimate partner violence (IPV) relationships, the incidence of violence among youth, especially adolescents, is increasing. For example, forms of aggression are becoming more commonplace in adolescent relationships, resulting in increased health risk for youth (CDC, 2006a, 2009). Teen dating violence is correlated with increased rates of suicide, alcohol use, and sexual activity (Kaminski and Fang, 2009). Male and female adolescents who are sexually harassed have increased rates of substance abuse and suicide. In young girls, particularly, sexual harassment is associated with eating disorders and self harm (Chiodo et al, 2009).

Although some violence may have decreased, the aftermath of the violence in our streets, in our schools and in our homes threatens the health and well-being of our entire population.

It is not clear from research if violence stems from an innate aggressive drive or is a primarily learned behavior. Clearly, all human beings have the capability for violence, yet what constitutes violence continues to be a subject for debate. Therefore, it is important to understand the theoretical and situational context in which violence is discussed (Malley-Morrison and Hines, 2004).

Violence is a public health nursing concern. Significant mortality and morbidity result from violence. Communities across the United States are concerned about crime and violence rates. Medical, nursing, psychology, and social service professionals have been slow to develop a response to violence that is part of their daily professional lives. As a result, the estimated 3.5 million victims of violence annually may not receive the best care possible. In addition, the extent of their pain that could have been avoided by community health prevention efforts is unknown. Nurses can take a more active role in the development of community responses to violence, public policy, and needed resources.

Violence is generally defined as those non-accidental acts, interpersonal or intrapersonal, that result in physical or psychological injury to one or more persons. Violent behavior is predictable and thus preventable, especially with community action. The Centers for Disease Control and Prevention’s (CDC’s) Initiative, “Choose Respect,” was launched in 2006. The program has been adopted in multiple communities across the United States. The purpose of the program is to teach parents and adolescents about healthy relationships and to give them tools to deal with unhealthy relationships such as teen dating violence (CDC, 2006b). The Migrant Clinicians Network, an organization to help migrant and other poor transient workers, has developed a natural helper model for migrant workers, to work within their own community to identify and teach about IPV (Kugel et al, 2009). Based on models developed in the 1980s, communities are developing a coordinated response in which multiple agencies work together to assist with preventing IPV. In addition to the criminal justice system, advocates for women, health care providers, and employers are encouraged to learn about and assist their employees with issues of IPV (Pennington-Zoellner, 2009). The Wraparound Project (Dickers et al, 2009) is another program that focuses on prevention of interpersonal violence. Similar to models developed to assist clients recovering from myocardial infarctions, the project identified “teachable moments” to assist clients admitted to a hospital emergency room to receive culturally specific resources to prevent reoccurrence of interpersonal violence. All of these community programs have the same goal: to decrease the incidence and prevalence of violence in our communities. In order to guide prevention of violence, a section of the Healthy People 2020 objectives is devoted to violence.

This chapter examines violence as a public health problem and discusses how nurses can help individuals, families, groups, and communities cope with and reduce violence and abuse. Nurses work with clients in a wide variety of settings, including the home. Since nurses are in key positions to detect and intervene in community and family violence, they need to understand how community-level influences can affect all types of violence.

HEALTHY PEOPLE 2020

Objectives for Reducing Violence

• IVP-29: Reduce homicides.

• IVP-35: Reduce bullying among adolescents.

• IVP-37: Reduce child maltreatment deaths.

• IVP-39: Reduce violence by current or former intimate partners.

• IVP-40: Reduce sexual violence.

From U.S. Department of Health and Human Services: Healthy People 2020 Objectives, Washington, DC, 2010c, Office of Disease Prevention and Health Promotion, USDHHS.

Social and Community Factors Influencing Violence

Many factors in a community can support or minimize violence. Changing social conditions, multiple demands on people, economic conditions, and social institutions influence the level of violence and human abuse. The following discussion of selected current social conditions helps to explain factors that influence violent behavior.

LINKING CONTENT TO PRACTICE

According to the Quad Council Domains of Public Health Nursing Practice (Association of State and Territorial Directors of Nursing, 2003) and the American Public Health Association (2010), public health nurses must collaborate in partnership with communities to assess and identify community needs; plan, implement, and evaluate community-based programs; and assist in the setting of policy that will contribute to the needs of the community in relationship to all types of interpersonal violence. The Quad Council competencies in the analytic assessment domain direct nurses to conduct thorough health assessments of individuals, families, communities, and populations and to develop diagnoses for the population being assessed (Council on Linkages, 2010). Public health nurses can help the community in many ways as is described throughout this chapter.

Work

Productive and paid work is an expectation in mainstream American society. Work can be fulfilling and contribute to a sense of well-being; it can also be frustrating and unfulfilling, contributing to stress that may lead to aggression and violence. Unemployment and changing patterns of employment are also associated with violence both within and outside the home.

When jobs are repetitive, boring, and lacking in stimulation, frustration mounts. Some work environments discourage creativity and reward conformity and “following the rules.” In many work settings, people try to get ahead regardless of the cost to others. Workers often go home feeling physically and psychologically drained. They may have worked at a back-breaking pace all day only to be yelled at by the boss for what seemed like a trivial oversight. It is hard to separate feelings generated at work from those at home. For example, a father arrives home feeling tired, angry, and generally inadequate because of a series of reprimands from his boss. Soon after he sits down, his 4-year-old son runs through the house pretending to fly a wooden airplane. After about three loud trips past his father, who keeps shouting for the child to be quiet and go outside, the airplane hits the father in the head. The father may hit the boy out of frustration and anger.

During economic downturns, people hesitate to give up jobs that are frustrating, boring, or stressful. Family needs may necessitate that they keep the hated job. Workers feel trapped and may resent those who depend on them. This frustration and resentment may lead to violence.

Unemployment may precipitate aggressive outbursts. The inability to secure or keep a job may lead to feelings of inadequacy, guilt, boredom, dissatisfaction, and frustration. Unemployment does not fit the image of the ideal man in American society, and these men are more likely to be violent both within and outside the family (Ellison et al, 2007; Peralta, Tuttle, and Steele, 2010). Women who experience IPV often lose their jobs because of constant harassment and stalking from the abuser and their subsequent absenteeism. Women who are stalked at work often find their jobs in jeopardy because of work interruption, continual stress, and decreased job performance. Slowly, employers are beginning to understand the implications of IPV. More women are finding support from employers when they disclose possible or actual abuse (Logan, Cole, and Capillo, 2007; Swanberg, Macke, and Logan, 2007).

Unemployment remains a risk factor associated with domestic violence (Ellison et al, 2007). Statistics from the U.S. Department of Labor (2010) showed that young, minority men have the highest rates of unemployment in the United States, ranging upward to 50% even in times of prosperity. This group also has the highest rate of violence. They live in a world of oppression, with lack of opportunity and enormous anger. They believe they are pushed out of mainstream society and are on the receiving end of the fallout of policies that ignore their dilemmas and give them no stake in mainstream America. Most analyses conclude that the differential rates of violence between African Americans and whites in the United States have more to do with economic realities, such as poverty, unemployment, and overcrowding, than with race (Ellison et al, 2007).

Education

In recent years, schools have assumed many responsibilities traditionally assigned to the family. Schools teach sexual development, discipline children, and often serve as a safe haven where children are fed and given the developmental support needed. Large classes often mean that teachers spend more time and energy monitoring and disciplining children than challenging and stimulating them to learn. As more and more social problems arise, it is often the expectation that the school system will teach children about these issues. One such issue is bullying. Bullying has become a major problem in U.S. schools. Bullying can be physical and/or psychological abuse, intimidation, or verbal abuse; the exclusion of some children in group activities is another form of bullying. Bullying takes place across ethnic groups and developmental age and is identified as an antecedent for perpetration of domestic violence (Corvo and deLara, 2010; Vervoort, Scholte, and Overbeek, 2010). Bullying can have devastating effects on health and can lead to self harm (Salmivalli, 2010). Cyberbullying, a form of hostile and intentional electronic communication, takes place constantly. It often leads to depression, isolation, and absenteeism. Many schools and parent groups are targeting bullying behavior on a larger scale by focusing on peer groups and population-based interventions (Berlan et al, 2010; Kiriakidis and Kavoura, 2010).

In large classes, children who do not conform to norms of expected behavior are often isolated. The non-conforming child is simply removed from the classroom because time is not available to help the child learn alternative forms of behavior. Often an end result is that there are two victims: children who are bullied and those who are the aggressor.

At times parents punish children for hitting or biting other children by spanking them. Also, spanking may be used in some schools. Such punishment only reinforces the child’s tendency to strike out at others. Schools are often places where the stressors and frustrations that can contribute to violence are rampant, and violence is learned rather than discouraged; yet school can be a powerful contributor to non-violence. Classes can help adolescents learn peaceful conflict resolution and help young children deal with the threat of sexual abuse and the issues of date rape (Regan, 2010). Parents can be advised of the availability of such programs, and school boards should be urged to adopt them into the curriculum.

Media

The media can be instrumental in campaigns against violence. Recent television programs, both documentaries and dramatizations, and print articles have heightened public awareness about family violence. Programs that raise the social awareness of IPV may play a role in reducing violence in interpersonal relationships (Regan, 2010). Social marketing techniques and public service announcements serve as mechanisms to inform the public of community resources supporting victims of interpersonal violence and serve as mechanisms to prevent intimate violence (Grier and Kumanyika, 2010). Abused women and rape victims have especially benefited from media attention, which tends to lessen the stigma of such victimization. The media are also useful in publicizing services.

Television, movies, newspapers, and magazines show happy, fun-loving people. Television depicts all the wonders money can provide; yet for many Americans, the hope of buying many of the products being advertised is unrealistic. Such polarization between what is available and what is possible provides fertile ground for the development of abusive patterns. Frustration, unfulfilled dreams, and unmet wishes are often handled through hurting someone who cannot fight back. On the other hand recent research shows little direct correlation between television viewing and interpersonal violence (Ferguson and Kilburn, 2009; Ferguson, San Miguel, and Hartley, 2009).

The media cater to children by advertising products to buy and things to do. Parents may get angry when their children request the foods, toys, and clothes they see on television, in magazines, or in newspapers or hear advertised on the radio. In addition, many toys and video games encourage violence through play.

Too often, the media portray the world as a violent place. When people think that violence is rampant, there are two possible results. People may become blasé about violence and no longer feel outraged and galvanized to action when terrible things happen in their community. On the other hand, some people might become frightened of their neighbors, isolate themselves, and refuse to become involved when someone needs help. Neither response is useful in any community action program.

Organized Religion

Historically, a seemingly contradictory relationship exists between abuse and religion. For example, many religious groups uphold the philosophy of “spare the rod, spoil the child.” Also, although divorce is socially accepted, some faiths uphold the victimization of people with their disapproval of divorce. Family members may stay together, although they are at emotional or physical war with one another, because of religious commitments. Although women have claimed that their spirituality has helped them in times of despair and victimization, they maintain that religious doctrine and some clergy become barriers to women seeking help or from leaving an abusive relationship (Beaulaurier et al, 2007; Potter, 2007).

Although churches have been slow to recognize domestic violence, some changes are taking place. Issues of male domination over women have become a major topic of discussion in some church groups, whereas in other groups women continue to be blamed for abuse that they sustain (Levitt and Ware, 2006). Religious affiliation and religious conservatism have been identified as risk factors for family violence, particularly child abuse (Hines and Malley-Morrison, 2005). Clergy need to be taught about the nature and dynamics of violence in the family, about religious messages and the potential for support, and about the need for collaboration between the church and advocates for the prevention of domestic violence. In religious groups where there is collaboration with advocates against abuse to children, women, and elders, there is a greater recognition of the harm of abuse and the clarity of the role of the clergy in dealing with abuse (Rodriguez and Henderson, 2010).

Population

A community’s population can influence the potential for violence. Density, poverty, and diversity, particularly racial tension and overt racism, contribute to violence. In addition, one’s perceptions of the safety in a community can be influenced by racism and perceptions of criminality (Lin, Thompson, and Kaslow, 2009; Howard, Budge, and McKay, 2010).

High-population-density communities can positively or negatively influence violence. Those with a sense of cohesiveness may have a lower crime rate than areas of similar size that lack social and cultural groups to support unity among members. Bonds formed among church groups, clubs, and professional organizations may promote harmony among members. Such groups provide members an opportunity to talk about stressors rather than to respond through violence. For example, residents of public housing often form neighborhood associations to deal with situations common to many or all residents. Tension can often be released in a productive way through projects carried out by the association.

Some high-population areas experience a community feeling of powerlessness and helplessness rather than one of cohesiveness. Lack of jobs and low-paying jobs may lead to feelings of inadequacy, despair, and social alienation. Social alienation and exclusion from opportunities can lead to decreased social cohesion and increased violence (Lee and Ousey, 2005; Rahn et al, 2009). Fear and apathy may cause community residents to withdraw from social contact. Withdrawal can foster crime because many residents assume someone else will report suspicious behavior, or they fear reprisals for such reports (Gracia and Herrero, 2007).

Youths often attempt to deal with feelings of powerlessness by forming gangs. Poverty and lack of education appear to be the overriding risk factors. A number of these young adults have attempted to deal with their feelings by turning to crime against people and property to release frustration. In many cities, these gangs have been highly destructive. Through community mobilization efforts, primary prevention programs have been developed to deal with the disenfranchisement of youth and gang violence (Pitts, 2009).

Other high-population areas may be characterized by a sense of confusion, resulting in disintegration and disorganization. These areas may have transient populations with limited physical or emotional investment in the community. Lack of community concern allows crime and violence to go unchecked and may become a norm for the area. Also, as crime increases, residents who are able to move leave the area. This increases community disintegration because the residents who leave are often the most capable members of the population.

The potential for violence also tends to increase among highly diverse populations. Differences in age, socioeconomic status, ethnicity, religion, or other cultural characteristics may disrupt community stability. Highly divergent groups may not communicate effectively and neither accept nor understand one another. Many such groups become hostile and antagonistic toward one another. Each group may see the other as different and not belonging. The alienated group may become the focal point for the others’ frustrations, anger, and fears. Racism, classism, and heterosexism are examples of major causes of community disintegration resulting in a vicious cycle of dishonesty, distrust, and hate.

Community Facilities

Communities differ in the resources and facilities they provide to residents. Some are more desirable places to live, work, and raise families and have facilities that can reduce the potential for crime and violence. Recreational facilities such as playgrounds, parks, swimming pools, movie theaters, and tennis courts provide socially acceptable outlets for a variety of feelings, including aggression.

Spectator sports, such as football or hockey, also allow members of the community to express feelings of anger and frustration. However, viewing sports can encourage a sense of violence as participants hit or shove one another.

Although the absence of such facilities can increase the likelihood of violence, their presence alone does not prevent violence or crime. These facilities are adjuncts and resources that residents can use for pleasure, personal enrichment, and group development.

Familiarity with factors contributing to a community’s violence or potential for violence enables nurses to recognize them and intervene accordingly. It is the nurse’s responsibility to work with the citizens and agencies of the community to correct or improve deficits.

Violence Against Individuals or Oneself

The potential for violence against individuals (e.g., murder, robbery, rape, and assault) or oneself (e.g., suicide) is directly related to the level of violence in the community. Persons living in areas with high rates of crime and violence are more likely to become victims than those in more peaceful areas. The major categories of violence addressed in this chapter are described in terms of the scope of the problem in the United States and underlying dynamics.

Homicide

Homicide is the leading cause of death for children and youth between the ages of 1 and 9 years and the second leading cause of death for young African-American women ages 15 to 34; for young Native-American women ages 20 to 34; and the fourth-, third-, and fifth-leading causes of death for white women 15 to 19, 20 to 24, and 25 to 34, respectively (CDC, 2009). However, the African-American homicide rate has decreased significantly since 1970, whereas the white homicide rate has increased slightly (USDOJ, 2009b). Although the data are not adequate, it also appears that Hispanic-American men have a much higher rate of homicide than non–Hispanic-American whites. Homicide rates are highest among young adults followed by young adolescents (14 to 17 years old), but homicide occurs at an alarming rate even among very young children in the United States. Rates of homicide for children under the age of 1 year were highest in American Indian/Alaska Native and African-American infants (CDC, 2007). The majority of homicides of children are perpetrated by parents. Only 15% of male and 9% of female homicides in the United States are caused by strangers (USDOJ, 2009b). When strangers are involved, many of these homicides are related to the illegal substance abuse network. The vast majority of homicides, however, are perpetrated by a friend, acquaintance, or family member. Therefore, prevention of homicide is at least as much an issue for the public health system as for the criminal justice system.

At least 16% of male homicides and 64% of female homicides in the United States occur within families, and half of these occur between spouses. These numbers, however, do not include unmarried couples who are living together or those who are either divorced or estranged, a group at higher risk. In total, approximately 14% of all homicides were committed by an intimate partner. Spouses or ex-spouses comprised about 24% of the perpetrators in female spousal homicides. Twenty-one percent of boyfriends or girlfriends and 19% of family members were responsible for female intimate partner homicides. Female homicides primarily are perpetrated by someone known to the victim. Only 10% of all female homicides were perpetrated by a stranger (Catalano et al, 2009).

An alarming aspect of family homicide is that small children often witness the murder or find the body of a family member (Lewandowski et al, 2004). No automatic follow-up or counseling of these children occurs through the criminal justice or mental health system in most communities. These children are at great risk for emotional turmoil and for becoming involved in violence themselves (Steeves and Parker, 2007).

The underlying dynamics of homicide within families vary greatly from those of other murders. Homicide within families is most often preceded by abuse of a family member, and homicides of intimate partners (male or female) are preceded by abuse of the female partner in 70% to 75% of cases (Campbell, Sharps, and Glass, 2000; Campbell et al, 2003). Thus, prevention of family homicide involves working with abusive families. Homicide is the leading cause of death for pregnant and post-partum women (Nannini et al, 2008). In fact, in a study of intimate partner homicide of women, 75% of the women who were killed by their husband, boyfriend, or ex-partner had been seen in a health care setting within the year prior to their homicide (Woods et al, 2008). Nurses have a duty to warn family members of the possibility of homicide when severe abuse is present, just as they warn of the hazards of smoking. Other nursing care issues are further discussed under Family Violence and Abuse in this chapter.

Assault

The death toll from violence is staggering, yet the physical injuries and emotional costs of assault are equally important issues in terms of the acute health care system. Twenty-two percent of females compared with 7.4% of males reported injury related to physical assault. Women are three times more likely than men to be killed by an intimate partner. Forty percent of women with disabilities claimed to have experienced IPV (VAWR, 2009). Age is the greatest risk factor for an individual’s victimization through violence, and youths are at significantly higher risk. Although more males than females are victims of homicide and assault, women are more likely to be victimized by a relative, especially a male partner (Catalano et al, 2009). Sometimes the difference between a homicide and an assault is only the response time and the quality of emergency transport and treatment facilities. The same community measures used to address homicide are useful to combat assault. Also, nurses often see assaulted persons in home health care with long-term health problems such as head injuries, spinal cord injuries, and stomas from abdominal gunshot wounds. In addition to physical care, nurses must also address the emotional trauma resulting from a violent attack by helping victims talk through their traumatic experience to try to make some sense of the violence, and by referring them for further counseling if anxiety, sleeping problems, or depression persists after the assault.

Rape

Currently, rape is one of the most underreported forms of human abuse in the United States with only about half (47%) of rapes in the National Crime Victimization Survey (NCVS) reported to police (Catalano et al, 2009), although reporting rates have improved over the past 15 years. According to the NCVS (Rand, 2009) sexual assault rates fell by 52% from 1999 to 2008. The rates of completed and attempted rape are almost equivalent. The incidence of rape exceeds the prevalence of rape victims because some victims experience more than one rape in a 12-month period. In 2008, according to the NCVS, there were an estimated 182,000 rapes or sexual assaults against females 12 or older, whereas males experienced 40,000 rapes or sexual assaults. This is a rate per 1000 of approximately 1.4 and 0.3, respectively. African-American females experienced higher rates of rape or sexual assault than white females and other women of color. Hispanic and non-Hispanic white females experienced comparable rates of sexual assault (Catalano et al, 2009). Over half the rapes or sexual assaults against females were committed by an offender whom they knew and one in five committed by an intimate partner. Strangers only committed about one third (31%) of all rape/sexual assaults. Nearly half (47%) of the rape and sexual assaults against females in 2009 were reported to the police. The rate of rape or sexual assault against females declined by 70% from 1993 to 2008 and by 36% during that period for males (Catalano et al, 2009). Since the majority of violence against women is IPV and women are raped more often by someone they know than by strangers, be alert for date and marital rape. In the National Violence Against Women Survey (Tjaden and Thoennes, 2000), 64% of rapes, physical assaults, and stalkings were committed against women by either current or former intimate partners. Official recognition of rape regardless of a victim’s relationship to the perpetrator has led to an increased number of women reporting rape. Rape also happens to men, especially boys and young men, but the statistics on the incidence of male rape vary. In a survey of Air Force women, over 50% had reported being a victim of rape at some time in their lifetime. While the majority of rapes occurred prior to enlistment, 14% of women were raped for the first time in the military and 26% of women were victims of rape prior to and within the military (Bostock and Daley, 2007). It appears that the emotional trauma for a male rape victim is at least as serious as that for a woman.

For reported rapes, cities constitute higher risk areas than do rural areas, and the hours between 8 PM and 2 AM, weekends, and the summer months are the most critical times. In about half of rapes among strangers, the victim and the offender meet on the street, whereas in other cases the rapist either enters the victim’s home or somehow entices or forces the victim to accompany him or her.

Prevention of rape, like that of other forms of human abuse, requires a broad-based community focus for educating both the community as a whole and key groups such as police, health providers, educators, and social workers. Rape rates and community-level variables such as community approval and legitimization of violence (e.g., violent network television viewing and permitting corporal punishment in schools) appear related and underscore the need for community-level intervention (Casey and Lindhorst, 2009).

DID YOU KNOW?

Between 40% and 45% of physically abused women are also being forced into sex. This has implications for the prevention of unintended and adolescent pregnancies, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and sexually transmitted diseases (STDs), as well as for women’s healthy sexuality and self-esteem.

Attitudes

The first priority is to change attitudes about rape and about victims or survivors. Rape is a crime of violence, not a crime of passion. The underlying issues are hostility, power, and control rather than sexual desire. The defining issue is lack of consent of the victim. When a woman or man refuses any sexual activity, that refusal means “no.” People have the right to change their mind, even when they seemed initially agreeable. Pressure from physical contact, threats, or deliberate inducement of drug or alcohol intoxication is a violation of the law. The myths that women say “no” to sex when they really mean “yes” and that the victims of rape are culpable because of the way they dress or act must end. On college campuses, negative attitudes toward acquaintance or date rape are slow to change. Women on college campuses underreport allegations of rape because of issues of confidentiality and fear of being discredited (Bachar and Koss, 2001). Another form of rape is forced sexual initiations, with as many as 21% of young women in the United States whose first sexual experience is below the age of 14 reporting that this initiation was physically forced, usually by a date or boyfriend (Stockman, Campbell, and Celentano, 2010). These early sexual experiences are associated with unplanned, adolescent pregnancies as well as HIV/STD risk behaviors.

Pornography

Although there is evidence of a relationship between the viewing of pornographic material showing violence against women and aggressive sexual behavior, it is not clear if the relationship is causal. In other words, our current research does not yet show that viewing pornography occurs before sexual aggressiveness or that young men who are sexually violent tend to watch pornography. The current research tends to minimize the relationship between sexual assault and pornography (Ferguson and Hartely, 2009). However, there is some evidence that claims that early exposure to pornography as a child may be related to sexual offense in the future (Seto and Lalumière, 2010). Prevention programs, or more accurately labeled risk reduction or avoidance programs, also involve providing information to women about self-protection, including using self-defense procedures, avoiding high-risk locations, and safeguarding one’s home against unwanted entry. Most rape prevention programs have been oriented toward women. Men are beginning to take some steps toward prevention toward women via anti-rape websites (Masters, 2010). Many of these websites are community-based programs that promote education about violence against women and promote a positive male role model of gender equity.

Victim or Survivor?

During the act of rape, survivors are often hit, kicked, stabbed, and severely beaten. It is this violence that is most traumatic because of the survivors’ fear for their lives, helplessness, lack of control, and vulnerability.

People react to rape differently, depending on their personality, past experiences, background, and support received after the trauma. Some cry, shout, or discuss the experience. Others withdraw and fear discussing the attack. During the immediate as well as the follow-up stages, victims tend to blame themselves for what happened. When working with rape victims, help them identify the issues behind self-blame. While not placing fault on survivors, teach them to take control, learn assertiveness, and therefore believe that they can take certain actions to prevent future rapes. Survivors need to talk about what happened and to express their feelings and fears in a non-judgmental atmosphere. Non-judgmental listening is important (Ullman, 2010).

In any psychological trauma, victims should be given privacy, respect, and assurance of confidentiality. They should also be told about health care procedures conducted immediately after the rape and should be linked with proper resources for ease of reporting the crime. Nurses often provide continuous care once the victim enters the health care system. Because many victims deny the event once the initial crisis is past, a single-session debriefing should be completed during the initial examination. The physical assessment, examination, and debriefing should be carried out by specially trained providers.

As discussed in Chapter 44, in most states, nurses trained as sexual assault nurse examiner (SANE), a subspecialty of forensic nursing, perform the physical examination in the emergency department to gather evidence (e.g., hair samples, skin fragments beneath the victim’s fingernails, evidence from pelvic examinations using colposcopy) for criminal prosecution of sexual assault (Sheridan, 2004). This is an important nursing intervention because physicians may not be able to take the time required for this procedure; nurses can take advantage of this opportunity to provide therapeutic communication and support. Nurses can be trained to conduct the examination either in SANE trainings or in Forensic Nursing programs in many schools of nursing, and their evidence is credible and effective in resultant court proceedings (Houmes, Fagan, and Quintana, 2003; Campbell et al, 2006; Campbell et al, 2007). Nurses can lobby for changes in hospital policies and state laws to make this strategy a reality in all states.

Rape is a situational crisis for which advance preparation is rarely possible. Therefore, nursing efforts are directed toward helping victims cope with the stress and disruption of their lives caused by the attack. Counseling focuses on the crisis and the concomitant fears, feelings, and issues involved. Nurses can help survivors learn how to regroup personal strengths. If post-traumatic stress disorder (PTSD) occurs, professional psychological or psychiatric treatment is indicated.

Many rape victims need follow-up mental health services to help them cope with the short- and long-term effects of the crisis. The time after a rape is one of disequilibrium, psychological breakdown, and reorganization of attitudes about the safety of the world. Common, everyday tasks often tax a person’s resources, and they may forget or fail to keep appointments. Nurses can make referrals and obtain the victim’s permission to remain in telephone contact in order to assess support, provide encouragement, and offer resources.

Suicide

Suicide, according to the National Violent Death Reporting System (NVDRS), accounted for the highest rate of violent death in 2007, taking the lives of 9245 people. Firearms accounted for 50.7%, hanging/strangulation/suffocation for 23.1%, and poisoning for 18.8% of suicides. Firearms (56%) or hanging/strangulation/suffocation (24.4%) were the most common form of suicide for men. Women used poisoning (40.8%) most frequently, followed by firearms (30.9%). Precipitating factors for suicide were mental health (45%), IPV (30%) and physical health problems (21.4%) (CDC, 2010b). The risk for death by suicide is greater than for death by homicide. Rates of completed suicide are higher for men, especially older adults, non-Hispanic whites, and Native Alaskans/American Indians (NA/AI) (Karch, Dahlberg, and Patel, 2010). Affluent and educated people often have higher rates of suicide than do the economically and educationally disadvantaged except for NA/AI populations who are often poor and yet commit suicide in alarming numbers. The presence of a gun in the home is an important risk factor for both suicide and homicide (Campbell, 2007).

Suicide is the third-leading cause of death among young people ages 15 to 24. In 2007, for every 100,000 young people in each age group the following number died by suicide: Between the ages of 15 and 19, 6.9 per 100,000 and from 20 to 24, 12.7 per 100,000 (NIMH, 2010). Boys and young men between the ages of 15 and 19 were five times more likely to commit suicide than females and four times more likely if between the ages of 20 and 24 (Karch, Dahlberg, and Patel, 2010). Suicide was the cause of death for 12% for youth between the ages of 10 through 24 years. Attempted suicide was more prevalent for white, African-American, and Hispanic females than for these same males. Leading risk factors for adolescent suicide are mental health, unintended pregnancy, and sexually transmitted disease (STD), especially HIV (Eaton et al, 2010). An important risk factor for actual and attempted suicide in adult women is IPV.

Nurses need to be involved in the reduction of suicide and the care for victims because suicide affects the community, the family, and individuals. On a community level, nurses can be involved in a coordinated response to the prevention of suicide and the care of attempted suicides. Through their roles in public health and school nursing, they can help develop policies and protocols for suicide across the life span. Nursing care may focus on family members and friends of suicide victims. Survivors, while angry at the dead person, may turn the anger inward. They may question their own liability for the death and have difficulty dealing with their feelings toward the dead person; survivors may limit their social activities because it is difficult for them and their friends to talk about the suicide. Nurses can help survivors cope with the trauma of the loss and make referrals to a counselor or support groups.

Family Violence and Abuse

Family violence, including sexual, emotional, and physical abuse, causes significant injury and death. These three forms of abuse tend to occur together as part of a system of coercive control. Generally, IPV is perpetrated by the most powerful against the least powerful. IPV is directed primarily toward women in heterosexual relationships (although they may physically fight back). According to the Bureau of Justice Statistics, 99% of IPV against females was perpetrated by males (Catalano et al, 2009). Although the rate of IPV has decreased for both females and males over the last 15 years, the rate of homicides perpetrated by a known other has remained the same (Catalano et al, 2009). IPV in same-sex relationships follows the same patterns of behavior as in heterosexual relationships. Similar to heterosexual relationships, males perpetrate the majority of IPV (Tjaden and Thoennes, 2000). Dynamics of power and control caused by race, gender expression, ability, immigration status, age, and class are methods of control in same-sex IPV (National Coalition of Anti-Violence Programs, 2010). Approximately 23% of gay males have been physically or sexually assaulted or stalked.

Recognizing the battered child or woman in the emergency department is relatively simple after the fact. It is unfortunate that, by the time medical care is sought, serious physical and emotional damage may have been done. Nurses are in a key position to predict and deal with abusive tendencies. By understanding factors contributing to the development of abusive behaviors, nurses can identify incidents of IPV.

Development of Abusive Patterns

Perpetrators of IPV often believe that violence within an interpersonal relationship is a normal behavior pattern (Stover et al, 2010). Factors that characterize people who become involved in IPV include upbringing, living conditions, and increased stress. Understanding how these factors influence the development of abusive behavior can help the nurse manage abusive families.

Upbringing

Of all the factors that characterize the background of abusers, the most predictable one is previous exposure to some form of violence (Whiting et al, 2009). As children, abusers were often beaten or witnessed the beating of siblings or a parent. These children learn that violence is a suitable way to manage conflict.

For both men and women, witnessing abuse as children was associated with abuse of their children. Factors of financial solvency and support tended to decease the incidence of child abuse (Dixon, Browne, and Hamilton-Giachritsis, 2009; Whiting et al, 2009). Childhood physical punishment teaches children to use violent conflict resolution as an adult. A child may learn to associate love with violence because a parent is usually the first person to hit a child. Children may think that those who love them are also those who hit them. The moral rightness of hitting other family members thus may be established when physical punishment is used to train children, especially when it is used more than occasionally. These experiences predispose children ultimately to use violence with their own children.

As well as having a history of child abuse themselves, people who become abusers tend to have hostile personality styles and be verbally aggressive. They have often learned these characteristics from their own childhood experiences. Their parents may have set unrealistic goals, and when the children failed to perform accordingly, they were criticized, demeaned, punished, and denied affection. These children may have been told how to act, what to do, and how to feel, thereby discouraging the development of normal attachment, autonomy, problem-solving skills, and creativity (Dixon, Hamilton-Giachritis and Brown, 2005). Children raised in this way grow up feeling unloved and worthless. They may want a child of their own so that they will feel assured of someone’s love.

Because of their experiences of trauma and to protect themselves from feelings of worthlessness and fear of rejection, abused children form a protective shell and grow increasingly hostile and distrustful of others. The behavior of potential abusers reflects a low tolerance for frustration, emotional instability, and the onset of aggressive feelings with minimal provocation. Because of their emotional insecurity, perpetrators of abuse often depend on a child or spouse to meet their needs of feeling valued and secure. When their needs are not met by others, they become overly critical. Critical, resentful behavior and unrealistic expectations of others lead to a vicious cycle. The more critical these people become, the more they are rejected and alienated from others. Abusive individuals tend to perceive that the target of their hostility is “out to get” them. These distorted perceptions can be detected when parents talk about an infant crying or keeping them up at night “on purpose” (Dixon et al, 2005).

Increased Stress

A perceived or actual crisis may precede an abusive incident. Because a crisis reinforces feelings of inadequacy and low self-esteem, a number of events often occur in a short time to precipitate abusive patterns. Unemployment, strains in the marriage, or an unplanned pregnancy may set off violence, especially in people with other risk factors such as a history of trauma themselves.

The daily hassles of raising young children, especially in an economically strained household, intensify an already stressed atmosphere for which an unexpected and difficult event may provoke violence. Stressful life events, poverty, and cultural values and social isolation are often associated with family violence. Crowded living conditions may also precipitate abuse. The presence of several people in a small space heightens tensions and reduces privacy; tempers flare because of the constant stimulation from others.

Social isolation is associated with abuse in families (Hines and Malley-Morrison, 2005). Such isolation reduces social support, decreasing a family’s ability to deal with stressors. The problem may be intensified if a violent family member tries to keep the family isolated to escape detection. Therefore, when a family misses clinic or home visit appointments, nurses need to keep in mind that abuse may be present. Nurses can encourage involvement in community activities and can help neighbors reach out to neighbors to help prevent abuse.

Frequent moves disrupt social support systems, are associated with an overall increased stress level, and tend to isolate people, at least briefly. Mobility can have a serious negative effect on the abuse-prone family. These families do not readily initiate new relationships; they rely on the family for support. Resources may be unfamiliar or inaccessible to them. Because frequent moving may be both a risk factor for abuse and a sign of an abusive family trying to avoid detection, nurses should assess such families carefully for abuse.

Types of Family Violence

Because various forms of family violence and violence outside the home often occur together, nurses who detect child abuse should also suspect other forms of family violence. When older adult parents report that their (now adult) child was abused or has a history of violence toward others, the nurse should recognize the potential for elder abuse. Physical abuse of women is frequently accompanied by sexual abuse both inside and outside the marital relationship. Severe wife abusers may have a history of other acts of violence. Families who are verbally aggressive in conflict resolution (e.g., using name calling, belittling, screaming, and yelling) are more likely to be physically abusive. Although the various forms of family violence are discussed separately, they should not be thought of as totally separate phenomena.

No member of the family is guaranteed immunity from abuse and neglect. Spouse abuse, child abuse, abuse of older adults, serious violence among siblings, and mutual abuse by members all occur. Although these examples are not inclusive, they demonstrate the scope of family violence.

Child Abuse

A national survey estimated that in 2009, 702,000 unique reports of children and adolescents who were subjected to neglect, medical neglect, physical and sexual abuse, and emotional maltreatment (USDHHS ACF, 2010a). Of these children, 78% were victims of neglect; 18% were victims of physical abuse, 10% were sexually abused, and 8% were psychologically maltreated. The remaining 2% were medically neglected. This is probably a conservative figure, since only the most severe cases are reported. Except for sexual abuse, which is four times as high for girls as for boys, victims are equally distributed among sexually abused male and female children (USDHHS, 2010a).

Children also witness domestic violence (Berman et al, 2010). When children witness domestic violence, they may experience many psychological and physical problems. Children living in homes with parental violence are more likely to feel guilt over the abuse and suffer from post-traumatic stress syndrome more than children who are not exposed to violence (Scott, 2007; Kletter, Weems, and Carrion, 2009). Children who experience abuse need to understand that the abuse experience is not their fault. From a practical sense, children need to understand safety issues and what they need to do when abuse occurs (Ernst et al, 2008). Risk factors for abused children include factors such as strain on the economic resources of the family, lack of social support, abuse between parents, and problems with substance abuse. Some of the risk factors are identified in Box 38-1 (USDHHS, 2010a; Zimmerman and Mercy, 2010). Children who witness abuse react differently according to their age, level of development, and sex; their reactions are influenced by the severity and frequency of the abuse witnessed (Kelly, Gonzalez-Guarda, and Taylor, 2010).

BOX 38-1

DETERMINING RISK FACTORS FOR CHILD ABUSE

Ask the following questions or observe the following behaviors to determine if risk factors are present.