ery ten men are survivors of contact sexual violence (i.e., rape, being forced to penetrate, sexual coercion, or unwanted sexual contact), physical violence, or stalking by an intimate partner during their lifetime. Ten percent of American women and 2% of men experience stalking by an intimate partner. One in five women and one in seven men endure severe physical violence (i.e., hitting with a fist or hard object, kicking, pulling hair, slamming into objects, choking, suffocating, beating, burning, or wounding with a knife or gun) during their lifetime. Before the age of 18, 8.5 million women experience their first rape, 3.5 million are stalked, 1.5 million men are forced to penetrate, and 1 million experience stalking (CDC, 2022b).

Survivors are left with residual negative consequences, including injuries that require medical services, fear and anxiety regarding their safety, post-traumatic stress disorder (PTSD), chronic medical conditions, or death (CDC, 2022b). Up to 65% of murder-suicides in the US involve an intimate partner, and 96% of victims are female. Furthermore, up to 20% of intimate partner homicides involve additional victims who attempted to help the victim, such as family members, friends, neighbors, law enforcement responders, or even bystanders (NCADV, n.d.). Long-term effects may include decreased quality of life, low self-esteem, mental health conditions, addiction, attempted suicide, unplanned pregnancy, child abuse, and witness abuse (American College of Obstetricians and Gynecologists [ACOG], 2022).

The ACOG (2022) defines IPV as a "significant yet preventable health problem that affects millions of women regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational background" (p. 1). Women reporting IPV also fear being infected with a sexually transmitted infections (STI) by their partners. While partner treatment is recommended, the HCP should determine if there is an increased risk of IPV and avoid partner notification if deemed unsafe. As many as 20% of women seeking care at family planning clinics who report a history of IPV also report pregnancy coercion, and 15% report birth control sabotage that led to unintended or unwanted pregnancies (p. 2). Over 320,000 pregnant women are abused in the United States each year. IPV in pregnant women has been linked to poor weight gain, tobacco use, and anemia, leading to low birth weight, preterm delivery, fetal injury, placental abruption, and stillbirth. IPV is linked to severe injuries to women during the postpartum period and beyond, including acute injuries to the head, face, breasts, genitalia, and abdomen, or more non-acute symptoms such as chronic headaches, sleep and appetite disturbances, chronic pelvic pain, urinary frequency or urgency, irritable bowel syndrome (IBS), sexual dysfunction, STIs, or recurrent vaginal infections. The violence may continue to escalate postpartum, leading to homicide. Approximately $8.3 billion and 250,000 hospital visits are attributed to DV and SV annually (ACOG, 2022, p. 2). The lifetime economic cost is estimated at $3.6 trillion, including medical services, lost productivity from work, criminal justice, and other expenses (CDC, 2022b).

Risk and Protective Factors for Intimate Partner Violence (IPV)

Individual risk factors for IPV perpetrators include:

• being a survivor of physical or psychological abuse (one of the highest predictors of perpetration)
• low self-esteem
• low income
• low academic achievement/verbal IQ
• young age
• aggressive or delinquent behavior as a youth
• substance abuse
• depression or mental health conditions
• anger/hostility
• lack of nonviolent problem-solving skills
• antisocial or borderline personality traits
• poor impulse control
• a prior history of being physically abusive to others
• social isolation or having few friends
• unemployment
• emotional dependence or insecurity
• a belief in strict gender roles, hostility towards women, or attitudes that accept or justify IPV
• an unplanned pregnancy
• a desire for power and control (CDC, 2021b, para 4)

Relationship risk factors for IPV include:

• marital conflict, tensions, instability, or negative emotions within the relationship
• jealousy, possessiveness, dominance, and control of the relationship by one partner over the other
• economic stress
• unhealthy family relationships or interactions
• association with antisocial or aggressive peers
• parents with less than a high school education
• a lack of social support
• a history of experiencing poor parenting/physical discipline or witnessing IPV between parents as a child (CDC, 2021b, para 5)

 The CDC identifies the following community risk factors for IPV:

• poverty,
• low social capital (a lack of institutions, relationships, or norms that shape the community's interactions),
• poor neighborhood support or cohesion.
• weak community sanctions against IPV (such as neighbors that will not intervene when they witness violence)
• high density of places that sell alcohol (CDC, 2021b, para 6)

Societal factors that can lead to IPV are:

• traditional gender norms and gender inequality
• cultural norms that support aggression toward others
• societal income inequality
• weak health, educational, economic, and social policies/laws (CDC, 2021b, para 7)

Protective Factors for IPV

 Relationship factors that reduce the risk of IPV include high-quality friendships and societal support. Community factors that further deter IPV include neighborhoods with a collective cohesiveness and support that is willing to intervene for the common good. Additional protective factors include coordinating resources and services among community agencies (CDC, 2021b). A systematic review that explored risk factors and protective factors for IPV demonstrated that being older and married were considered protective factors. Higher education was also mentioned as a possible protective factor against IPV (Yakubovich et al., 2018).

Special Population Groups

                Adult women are frequently the survivors of DV and SV. However, special populations also at risk include children and adolescents, mentally or physically disabled or ill individuals, older adults, women of color, immigrant women, members of the LGBTQ+ (lesbian, gay, bisexual, transgender, and queer/questioning) community, those experiencing homelessness, low socioeconomic status (SES), and those living in remote or rural areas. Male patients can also be victims (ACOG, 2022; CDC, 2022b).

Children

About one in seven children experience abuse and neglect yearly in the United States. In 2008, the CDC attributed over $124 billion to the economic burden of child maltreatment. Children can be survivors of neglect or physical, sexual, or emotional abuse. This can be perpetrated by a parent, caregiver, teacher, clergy, or any other person of authority over the child (CDC, 2022a).

              Individual risk factors for child abuse are related to victimization, including age and special needs. A child under four is at higher risk than an older child as they may be unable to identify or report the events. Conditions such as autism, developmental delays, and chronic physical or mental illnesses increase the caregiver burden, increasing the risk of abuse or violence. Children living in poverty have five times the risk of abuse than children in higher socioeconomic environments (CDC, 2022a). Table 1 categorizes additional risk factors for this age group:

Table 1

Risk Factors for the Perpetration of Abuse in Children

Individual risk factors	poor parenting skills or lack of understanding regarding appropriate developmental needs history of previous child abuse or neglect substance abuse or mental health issues young or single parents, those with limited education, a large number of children, or a low income nonbiological or transient caregivers such as boyfriends or girlfriends of a parent parental thoughts or emotions that justify poor treatment of the child
Family risk factors	social isolation family dysfunction (e.g., divorce, violence, or IPV) poor relationships between parents or parent/child parenting stress
Community risk factors	violence within the community high poverty levels in the community high unemployment rates a large number of alcohol outlets, such as bars and liquor stores poor social connections

(CDC, 2022a)

Protective factors for children against abuse or neglect include:

• supportive family networks or social networks
• basic needs met
• strong parenting skills
• stable family relationships
• child monitoring and household rules
• parental employment
• adequate housing
• access to social services and healthcare
• adults outside the family who serve as role models or mentors
• supportive caregivers in the parent's absence
• community support that works to prevent abuse (CDC, 2022a)

The goal is to prevent abuse and neglect before it happens. Among the preventative techniques is to strengthen economic support to families through a family-friendly work policy or household financial security. Social norms and educational campaigns focusing on positive parenting and coaching are effective. Children should have quality care and education during their toddler, preschool, and early elementary years. These can be encouraged through state licensing and accreditation of daycare centers and early childhood programs. Initiatives such as early childhood programs and home visits can promote parenting skills and healthy child development. Finally, pediatricians and primary care providers should monitor for and intervene in high-risk situations where future abuse and neglect are suspected to minimize the effects and possibly avoid future concerns (CDC, 2022a).

Child abuse and neglect leave a long-lasting impact on survivors; Figure 2 highlights the potential concerns with adverse childhood experiences (ACE) over a lifetime:

Figure 2

The Adverse Childhood Experiences (ACE) Pyramid

(CDC, 2022a)

Laws vary related to circumstances that constitute children witnessing DV when the act is committed in the presence of a child. Nine states consider an act of violence in the presence of a child to be "aggravating circumstances" during their sentencing guidelines (Child Welfare Information Gateway, 2021).

In 15 states and Puerto Rico, witnessing DV by a child occurs when the child is present or can hear or see the violent act. According to Ohio laws, witnessing DV occurs when the child is within the vicinity of the act. This means within the same home or 30 feet of the act. Legal consequences for many states include a conviction for DV that occurred in the presence of a child, which may carry a harsher penalty. It is an “aggravating circumstance” in some states. Thus, sentencing guidelines typically suggest increased fines, longer incarceration time, or both. Additional penalties may include paying for counseling services that a child who witnessed the abuse may require (Child Welfare Information Gateway, 2021).

Preschool children exposed to IPV exhibit lower self-esteem and demonstrate more behavioral problems than school-age children. Thus, exposure to DV interferes with developing a sense of security and safety. These children develop increased attention toward threatening stimuli. This creates an increased risk of internalizing problems. It is associated with social withdrawal, depression, and social and general anxiety. A meta-analysis reported significantly more psychological adverse outcomes than children not exposed to DV or experienced physical abuse. Therefore, any childhood violence, which includes exposure to DV within the home, can detrimentally affect a child’s mental health (Muller, 2019). Studies have also shown that children and adolescents exposed to toxic stress can have negative changes in brain development. This stress can result from experiencing racism, having limited access to medical services, poverty, lack of food, living in impoverished neighborhoods, mental health issues, substance use disorder, and exposure to violence in the home (CDC, 2021b).

Adolescents

            Violence in youth and adolescents varies from that of most DV and SV. Bullying is reported by one in five high school students, and social media bullying is reported by one in seven. About 14 adolescents are victims of homicide each day, and 1,300 are treated at hospitals for non-fatal assaults and subsequent injuries. More than $21 billion is spent yearly on medical and related costs due to violence among adolescents (CDC, 2022d).

Youth violence can start early with bullying and physical aggression. While children as young as toddlers can be aggressive, they are expected to learn alternate ways to manage their emotions before entering school. Early childhood risk factors for later violence among adolescents include impulsive behavior, poor emotional control, and lack of problem-solving skills. These children may be survivors of DV, SV, or chronic stress, leading to altered brain development and perpetuating the cycle of abuse (CDC, 2022d).

Of particular concern among the adolescent population are young girls. Teen dating violence can include physical, sexual, psychological, or emotional abuse by an intimate partner and may involve stalking. According to the CDC (2023), 1 in 11 female and 1 in 15 male high school students report that they have experienced dating violence in the last year. One in nine females and 1 in 36 males reported sexual dating violence in the last year. Peer pressure can accelerate violence in this group, combined with a social environment that may influence teens to remain in unhealthy relationships to fit in socially. Adolescents are more likely to have mental health problems because of emotional, physical, and social changes, which include exposure to violence and poverty. Approximately 1 in 7 (14%) adolescents between 10 and 19 experience mental health conditions worldwide; these are typically untreated and unrecognized. These mental health conditions cause vulnerability to social exclusion, stigma, discrimination, risk-taking behavior, poor educational performance, and physical health conditions (CDC, 2023).

The CDC (2022d) offers a technical package on its website entitled A Comprehensive Technical Package for the Prevention of Youth Violence and Associated Risk Behaviors. Figure 3 outlines these strategies briefly.

Figure 3

Strategies to Prevent Youth Violence per the CDC

(CDC, 2022d)

The effects of youth violence are lifelong, including adverse health and well-being, future risk of violence in relationships, victimization, smoking, substance use, obesity, high-risk sexual behavior, depression, academic difficulties, school dropout, and suicide. Youth identified as survivors or perpetrators of abuse should be assessed for previous violence and abuse by others (CDC, 2022d).

Mentally or Physically Disabled or Ill 

Disability affects 12% of Americans and is associated with a higher risk of violence or victimization than the general population. People with disabilities have a greater prevalence of experiencing abuse throughout their lifetime than individuals who do not have a disability. They experienced crimes of violence at four times the rate of individuals who do not have a disability between 2017 and 2019, and women with disabilities are twice as likely to experience IPV as those who do not have a disability. Men with disabilities are more likely to be stalked or psychologically abused than those who do not have a disability (NCADV, n.d.)

              A survey by the Spectrum Institute’s National Disability and Abuse Project found that over 70% of the respondents with disabilities experienced some form of mistreatment by an intimate partner, family member, caregiver, acquaintance, or stranger. Verbal or emotional abuse, physical abuse, sexual abuse, neglect, and financial abuse were reported, with less than one-third of these reported to the police. Abuse among the disabled may also include unwanted sexual contact, threats, intimidation, withholding medications, physically harming service animals, isolation, withholding of necessary physical accommodations or assistive devices, or financially exploiting/misusing the victim's finances. Within this group, children and adolescents with autism, developmental delays, or other disabilities are at increased risk of victimization (NCADV, n.d.).

Women who have a developmental or physical disability are less likely to be able to care for themselves and rely more on their partners for assistance. This dynamic can be dangerous because the abusers can be in a position to cause physical abuse to their victims by preventing the use of assistive devices such as wheelchairs or walkers, withholding prescribed medications, and not providing assistance with other self-care needs such as toileting, bathing assistance, or eating. Unfortunately, many shelters do not accept women who have disabilities or do not provide the training to adequately assist patients with a disability with their needs (ACOG, 2022).

Individuals diagnosed with mental illness, especially women, are predisposed to abuse. These include PTSD, depression, and suicidal thoughts (American Psychiatric Association, n.d.). A further concern for individuals with mental illness is the risk of abusing others. For instance, someone with an antisocial personality has a lower distress tolerance and may have psychopathic traits that could increase the risk of violence towards partners or others. Healthcare workers should recognize the inherent risk of mental health disorders, as one in eight mental health patients report DV annually. Mental illness predisposes the individual to physical and emotional violence, both as a survivor and perpetrator (Brem et al., 2018).

Older Adults

              Abuse of an older adult is defined as an "intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult…60 years of age or older". Approximately one in ten Americans over 59 experience abuse or neglect annually. For every case reported, research suggests that an estimated 20 or more cases are unreported (CDC, 2021). Risk factors for a perpetrator may be individual, relational, community, or societal in origin. The HCP should understand the risk factors to identify opportunities for prevention. Table 2 lists the risk factors for perpetration in this age group:

Table 2

Risk Factors for the Perpetration of Abuse in Older Adults

(CDC, 2021a)

Protective factors for abuse of older adults include the individual having strong relationships with multiple people and avoiding isolation at the relationship level. Community protective factors support coordinating resources and services that serve older adults and their caregivers and effective monitoring systems within institutional settings. Policies and procedures, staffing, and oversight within a long-term care facility can decrease the opportunity for neglect or abuse. Regular visits by family members, social workers, and volunteers help to reduce the chances of abuse (CDC, 2021a).

The consequences of abuse in older adults are physical and psychosocial. While minimal studies have considered these consequences, experts agree on some aspects. These include physical injuries such as bruises, broken bones, pressure injuries, lacerations, or dental problems; persistent pain; nutrition and hydration issues; sleep problems; increased susceptibility to illness, including STIs; worsening of previous health conditions; or increased risk of death. Psychological effects can range from fear and anxiety to depression or PTSD (CDC, 2021a; Indu, 2018). While the HCP needs to understand the signs and effects of abuse in older adults, the nurse must help create awareness among the older adult population regarding their legal and social support opportunities and assist them in addressing situations where their safety is questionable. Older adults often do not seek help and fear retaliation or worsening conditions. A culture with zero tolerance for abuse or neglect and ongoing assessment can minimize the number of abuse cases among older adults in the United States (Indu, 2018).

The CDC recommends that HCPs listen carefully to older adults and their caregivers to assess challenges and needs accurately. HCPs should be aware of the indications of abuse and how these differ from the normal aging process. Isolated older adults with less social support networks are at increased risk and require more frequent assessments/check-ins. Caregivers should be supported by a network of friends and family members and connections with local relief/support groups or adult daycare programs for respite. Caregivers should be mindful of their own emotional and mental well-being, with active participation in counseling and other self-care activities. Any substance use should be identified early and managed aggressively, as this increases the risk of violence and abuse (CDC, 2021a).

People of Color and Immigrants

              The effects of IPV are disproportionately borne by women of color in the United States, including immigrants. Native American and Alaska Native (NA/AN) women report an IPV prevalence of 46%, and non-Hispanic Black women report an IPV prevalence rate of 43.7%, according to the National Intimate Partner and Sexual Violence Survey. Hispanic women report an IPV prevalence rate of 37.1%. While all women victimized by IPV report multiple health outcomes, these are found in higher rates among women of color. This may include fibromyalgia, joint disorders, hypertension, stomach ulcers, digestive problems, vision and hearing problems, memory loss, traumatic brain injury, depression, PTSD, low self-esteem, and suicidality. Survivors of sexual violence may develop vaginal and anal tearing, sexual dysfunction, pelvic pain, dysmenorrhea, pelvic inflammatory disease, cervical neoplasia, and STIs such as HIV at higher rates than those not exposed to violence. Women of color and immigrant women are more likely to live in poverty, have lower levels of education, and have less access to healthcare, which limits their ability to manage the adverse effects and complications of IPV (Stockman et al., 2015).

As many as 34% of NA/AN reported rape or sexual assault during their life, which is almost double the rate for the rest of the US population. However, the accuracy of reporting the prevalence of DV/SV within the native community is often questioned, as data is not officially gathered by federal or Indian agencies (Hardy & Rice, 2016). Homicide is one of the leading causes of death for women over 44, and most are by intimate partners. NA/AN women experience the highest rate of homicide at 4.4 and 4.3 per 100,000 population, respectively. Over half of these murders are IPV-related, and over 11% were victims of IPV in the months preceding their deaths (Petrosky et al., 2017). Women living on native reservations often have unique legal barriers due to the laws governing their territories and the rights of their residents (Hardy & Rice, 2016).

              Most of the abuse towards native women and children relates to historical victimization. The repression of NA/AN has limited their economic resources and caused a dependency through retracting tribal rights and sovereignty. Both groups suffer from the normalization of violence and internal oppression. Many perpetrators are found to use alcohol or drugs before violent events. A higher rate of substance use is often correlated with community issues, including repression, tribal laws, lack of medical or social support, and a fundamental lack of trust outside the NA/AN community. These factors can lead to alcohol and substance use, mental anguish, and suicide (Hardy & Rice, 2016).

              Risk factors for DV and SV in these populations include low SES, unemployment, gender, cultural affiliation, substance use, relationship status, history of exposure to violence, and previous childhood experiences. Residual effects of the abuse include depression, anxiety, chronic pain, substance use, promiscuity, suicidal ideation, decreased communal cohesion, and cardiovascular disease. Mental health resources on tribal lands are insufficient and substandard in quality. Poor access to care during a crisis and a lack of multicultural competency are pervasive concerns in mental healthcare among the native population. For example, while there are over 500 tribes within the US, only 26 native-specific shelters exist. HCPs and mental health practitioners should work to eliminate barriers for those who require mental health services and attempt to break the cycle of abuse through community-driven efforts. Interventions should focus on all four parts of the Native American Medicine Wheel: mental, spiritual, physical, and emotional. Several studies indicate a need for increased focus on spiritual exercises while working with NA/AN women. A multi-modal approach optimizes the care for survivors. Mental health, legislative changes, creating a trusting environment through culturally competent care by HCPs, and developing patient-centered approaches may provide the most significant outcomes. There is a need for more culturally specific shelters, along with a higher awareness of the significance of DV and SV in the NA/AN community (Hardy & Rice, 2016).

Immigrant women are more likely to experience IPV. As many as 48% of Latina women report increased IPV after immigrating to the US, and studies indicate a prevalence rate for Asian immigrant women at 24-60%. Language barriers, lack of knowledge about legal rights or processes, and the stress of relocating to a foreign country all contribute to this trend (Stockman et al., 2015). Individuals from various cultural backgrounds may view DV and SV differently and may not recognize certain behaviors as abusive. Immigrants may also hesitate to report DV or SV due to fear of deportation. These individuals need culturally appropriate care that is sensitive to accessibility issues, racism, language barriers, and acculturation. HCPs can help educate all patients that they have a right to live free of abuse and that DV is illegal in this country regardless of the person's immigration status or country of origin (ACOG, 2022; National Domestic Violence Hotline, n.d.).

LGBTQ+ (Lesbian, Gay, Bi-Sexual, Transgender, and Queer/Questioning)

According to the National Coalition of Anti-Violence Programs (NCAVP, 2018), over 43% of gay and 61% of bisexual women have experienced rape, physical violence, or stalking by an intimate partner during their lifetime; these statistics are in contrast to just over 35% of heterosexual women. Rape, physical violence, or stalking by an intimate partner was reported by 26% of gay men and 37% of bisexual men compared to 29% of heterosexual men. Only one-quarter of these assault survivors contacted the police, even with life-threatening attacks (NCAVP, 2018). More than half of nonbinary and transgender individuals (54%) experienced some form of IPV throughout their lives (American Psychiatric Association, n.d.).

Transgender individuals are more likely to experience IPV in public than cisgender individuals. They are more likely to experience harassment, threats, or intimidation. Black and African American LGBTQ individuals are more likely to experience IPV than LGBTQ individuals who do not identify as Black or African American. White LBGTQ individuals are more likely to experience sexual violence than their counterparts who do not identify as white. Finally, LGBTQ individuals on public assistance such as welfare or food stamps are more likely to experience IPV than their peers who are not on public assistance. The NCAVP (2018) noted that IPV in the LGBTQ community exists in concert with the broader bias towards this community. This is more pronounced in multiple vulnerabilities, such as LGBTQ individuals of color, disability, or undocumented immigrants. Research shows that LGBTQ individuals fall victim to DV at equal or higher rates than heterosexual individuals (NCAVP, 2018).

Violence among this group includes physical violence, verbal harassment, threats and intimidation, isolation, online or telephone harassment, stalking, sexual violence, or economic/financial violence. As many as 43% of survivors of IPV were denied access to emergency shelters in 2017. Of those, 32% reported the reason was related to their gender identity. Police may be indifferent to the LGBTQ survivor's report of IPV, and up to 11% noted the police were hostile (NCAVP, 2018).

Culturally appropriate care for the LGBTQ community is essential to meet their unique needs. Barriers to care, vulnerabilities, and lived experiences can create a culture that diminishes the group's needs. To prevent IPV among the LGBTQ community, lawmakers should fund specific prevention initiatives. Education should focus on the current problems the LBGTQ community is facing and encourage awareness of the issue within healthcare organizations and providers. Early intervention, preventative programs, and campaigns against IPV can change the outcomes for this vulnerable population (NCAVP, 2018).

Those Experiencing Homelessness

              Domestic violence was cited as the primary cause of homelessness (National Network to End Domestic Violence [NNEDV], n.d.). Low income, unemployment, economic stress, and poverty are risk factors for IPV perpetrators (CDC, 2022b). Between 22-57% of women experiencing homelessness report that the immediate cause is DV, which increases to more than 80% among mothers with children. Of all DV survivors, 38% will experience homelessness at one time. A Florida study of 800 women experiencing homelessness found that they are two to four times more likely to experience violence. Studies have identified a positive correlation between a history of food and housing insecurity and a history of rape, physical violence, or stalking in the last year (NNEDV, n.d.).

Socioeconomic Status and Rural Communities

               Higher levels of violence are associated with lower economic activity, a drop in employment, and decreased women in the workforce. IPV makes it more difficult for survivors to obtain and maintain employment. Individuals from abusive relationships work fewer hours and are not as productive when they do work. Poverty is a major reason for continuing a relationship where DV exists because the abuser has power and control over the victim. Multiple studies demonstrate that if a survivor of abuse has the resources to leave the relationship safely and has affordable housing, they are more likely to escape the abusive relationship. Unfortunately, individuals with low to no income may feel trapped in an abusive relationship, especially if children are involved. They rarely have the necessary resources to leave the violent situation. If they leave the relationship, many will return to the abusive partner to obtain the resources needed to care for their children. Many survivors return to the relationship because they have nowhere to go (SafeHouse Center, 2019).

              The effects of DV and SV in rural communities are directly related to limited access to resources/services, distance/transportation barriers, a lack of acceptance of alternative lifestyles, and a relative paucity of shelters and affordable housing. Survivors in small towns are less likely to report abuse if they or their abuser are familiar with their HCPs and law enforcement officers, citing concerns about not being believed, breaches in confidentiality, tarnished reputation, or escalated violence/retaliation. Only 41% of violent crimes in rural areas are reported, which artificially reduces the data on these crimes. To better understand DV and SV in rural areas, the National Advisory Committee on Rural Health and Human Services requested that a geographic variable be added to the National Intimate Partner and Sexual Violence Survey from the CDC to elucidate the level of urbanization (Rural Health Information Hub, 2021).

Male Victims/Survivors

Very few studies focus on the male survivor of DV or SV, and male victimization is under-reported, under-treated, and under-recognized by HCPs. "Abuse is overlooked in male survivors and may be due to prevailing cultural norms, myths, assumptions, stigma, and biases about masculinity" (Elkins et al., 2017, p. 116). Domestic abuse does not discriminate and occurs to men from all cultural backgrounds and occupations. Within any vulnerable group, men or women may be the victims; however, specific instances and situations relate to men who experience DV and SV. When a victim is a man and the perpetrator is a woman, there is a stronger social stigma associated with domestic violence. Domestic abuse is typically portrayed as a gender crime perpetrated by men toward women. The abuse can be psychological, physical, sexual, financial, or emotional. As many as one-third of men report being a survivor of DV or SV during their lifetime. The Office for National Statistics estimates that 1.6 million women and 757,000 men reported abuse in 2020 (The Center for Social Justice, 2022). Male survivors may not report abuse, feeling isolated in this experience, embarrassed by it, fearful that they will not be believed, or scared that their partner will become revengeful (HelpGuide, 2023). Unfortunately, males are less likely to be suspected of being a victim or asked about abuse, less likely to seek help, and less likely to be believed when reporting abuse than their female counterparts. Even when HCPs recognize abuse among males, the survivor may not realize it is abuse. Often, the provider fails to offer support and empathy, which prevents the victim from seeking help; thus, the abusive cycle continues (The Center for Social Justice, 2022).

There are significant consequences for the male survivor of DV and SV. The effects may be emotional, behavioral, or social. Sexually abused males have higher rates of PTSD, substance use, and suicide. High-risk sexual behavior, fighting, and dating violence are also common among survivors of SV. Perpetrators of male DV and SV may be male or female, regardless of sexual orientation. Men are more likely to report sexual abuse where the perpetrator is a family member; however, most SV in males is from non-family members. Given the low rates of self-disclosure of DV and SV among males, HCPs must be trauma-informed and do their part to create a culture that gives male survivors the same considerations as female survivors. However, gender-specific care should be administered to create a safe and supportive environment for male survivors of DV and SV (Elkins et al., 2017).

The Effects of the COVID-19 Pandemic on Domestic Violence

Multiple studies reviewed the prevalence and effects of COVID-19 and quarantine during the pandemic on domestic violence. Of these studies, 11 found a significant increase in the rates of IPV. Factors contributing to the rise include unemployment, lower socioeconomic status (compared to pre-pandemic), family mental illness, overcrowding, and a COVID-19 diagnosis within the family unit. Measures implemented to control the spread of COVID-19, such as social distancing and stay-at-home orders, increased the vulnerability to IPV and decreased access to support networks (McNeil, 2023). These measures were implemented to protect individuals from infection; however, they forced victims to be quarantined with their abusers. Unfortunately, the pandemic caused increased unemployment, especially among immigrants, women of color, and individuals without a college degree, exacerbating financial stress and entanglement. Public health measures implemented to limit the spread of COVID-19 decreased access to alternative housing as hotels and shelters decreased their capacity or shut down (Evans, 2020).

According to the American Journal of Emergency Medicine, there was a 25-33% global increase in DV cases in 2020. Domestic violence cases are more likely to be reported by heterosexual women but continue to be underreported in men, gender non-conforming, transgender, and same-sex relationships. The pandemic resulted in quarantine, but it also caused an increase in alcohol use, PTSD, and depression, all of which exacerbated IPV (Newman, 2021). Calls to DV hotlines, shelters, and police increased during the pandemic (World Health Organization [WHO], 2020).

The pandemic forced many providers to utilize telemedicine appointments, thus decreasing the number of face-to-face encounters. This also created barriers to assessing IPV and the ability to screen the client alone. Providers should screen for IPV during telemedicine appointments and discuss safety planning with the patient (Evans, 2020).

Prevention of DV/SV

                According to the CDC (2022b, 2023), prevention is the key to IPV reduction. In both teens and adults, they suggest “teaching safe and healthy relationship skills, engaging influential adults and peers, disrupting the developmental pathways that lead toward a cycle of family violence, creating protective environments, strengthening economic support for families, and finally supporting survivors to increase safety and lessen harms” (p. 2). The details of these steps for prevention are shown in Figure 4 (CDC, 2022b).

Figure 4

Preventing IPV

 

 

(CDC, 2022b)

 

The CDC (2022e) also developed the Public Health Approach to Violence Prevention (PHAVP), which outlines four clear steps to prevent violence:

 

1. define and monitor the problem
2. identify risk and protective factors
3. develop and test prevention strategies
4. assure widespread adoption (CDC, 2022e)

 

Healthcare facilities can adopt this approach through ongoing surveillance and reporting to the appropriate agencies. The first two steps focus on defining the problem by sharing statistics and understanding the risk and protective factors. PHAVP can create a trauma-informed culture that readily identifies survivors and patients at risk for victimization. Violence prevention aims to decrease the risk factors and increase protective factors. In the third step, strategies are explored and defined to develop the optimal interventions to reduce or prevent violence. Finally, in step four, strategies that have been proven successful are shared within the healthcare communities, and broad adoption of best practices takes place. Ongoing monitoring, assessment, and evaluation are necessary to stay ahead of trends or identify opportunities to improve interventions (CDC, 2022e).

 

To prevent SV, the CDC developed the acronym STOP SV, the components of which are depicted in Figure 5 (CDC, 2022c).

 

Figure 5

STOP SV

 

 

 

(CDC, 2022c)

 

Creating a culture of trauma-informed care or practice (TIC or TIP) can facilitate early recognition and intervention to decrease victimization (Wilson et al., 2015). The Center for Health Care Strategies (n.d.) describes TIC as shifting the focus from what is wrong with the survivor to what happened to the survivor. They further explain that healthcare organizations and teams must develop a complete picture of a patient’s past and present life situation to care for the entire patient with a healing orientation. If implemented optimally, TIC can improve patient outcomes, advance treatment adherence, reduce healthcare and social services costs, and promote HCP/staff wellness. It must be adopted at both the clinical as well as the organizational level. TIC seeks to:

 

• realize the widespread impact of trauma and understand paths for recovery
• recognize the signs and symptoms of trauma in patients, families, and staff
• integrate knowledge about trauma into policies, procedures, and practices
• actively avoid retraumatization (Center for Health Care Strategies, n.d., para. 2)

The SAMHSA (2014) defines TIC as including the four Rs (Table 3):

 

Table 3

The Four Rs of TIC

Realize

Recognize

Respond

Resist retraumatization

 

 (SAMHSA, 2014)

 

The four Rs approach corresponds with the CDC's four steps towards violence prevention. Either method (or a combined approach) applied consistently will create a trauma-informed culture and organization that meets the needs of DV/SV survivors (CDC, 2022e; SAMHSA, 2014).

 

Common Indicators of DV and SV

 

                To identify patients potentially experiencing DV or SV, the HCP must first be educated to recognize the signs and symptoms in all groups, including women, men, and all the vulnerable populations discussed in this module (Wilson et al., 2015). The following list of signs and symptoms are common indicators of abuse that HCPs should be watchful for when caring for patients:

 

• injuries that point to a defensive position over the face (bruises and marks on the inside of the arms or back)
• injuries to the chest and stomach, reproductive organs, and anus
• illness or injuries that do not match the cause given
• a delay in requesting medical care
• injuries and bruises of various colors, indicating that they did not occur together
• repeat injuries, or someone who is 'accident prone' with evidence of multiple healed fractures on x-ray
• ruptured eardrums
• injuries during pregnancy
• repeated reproductive health problems, such as repeat miscarriages, early delivery, STIs, vaginal discharge, or sexual dysfunction
• psychological or behavioral problems
• suicide attempts or signs of depression
• repeat and chronic medical concerns, pelvic issues and pains, psychological diseases, chronic headaches (including migraines)
• repeatedly missing work, school, or social obligations without explanation
• behavioral signs such as multiple visits seeking medical care; a lack of commitment to appointments; not displaying any emotion or crying very easily; an inability to undertake daily interactions; negligence; defensive positions; stilted speech; avoiding eye contact; discomfort in the presence of their partner; acting nervous or anxious; attempting to hide injuries with sunglasses, scarfs, or outerwear; and animosity in body language (HelpGuide, 2023)

If present, the abuser/partner may display extreme or irrational jealousy or possessiveness. Abusers may attempt to control the time spent with the provider or nurse by insisting on staying close to the patient and speaking on their behalf.

 

              Injuries may be physical, including bruises and fractures, quickly recognized by an HCP. However, the abused individual may exhibit various cardiovascular, gastrointestinal, reproductive, musculoskeletal, or central nervous system conditions, typically chronic and less obvious to the HCP. Mental health conditions such as depression and anxiety may be related to current or previous DV or SV (SAMHSA, n.d.). Survivors of DV or SV may present with reports of poor appetite, disturbed sleep, or mood disorder symptoms. Warning signs of abuse may also include asthma, stress-related illnesses, anxiety/panic attacks, vague aches and pains, chronic diarrhea, abdominal pain, bladder/kidney infections, joint pain, or muscle pain (HelpGuide, 2023).

 

Screening Tools

 

The primary role of HCPs is to recognize potential survivors of DV and SV, provide screening, and offer interventions and resources. In 2011, the Institute of Medicine recommended that IPV screening and counseling be included as core components of all women's health visits, further supported by the CDC (2014) and ACOG (2022). The US Preventive Services Task Force (USPSTF, 2018) recommends the universal screening of all women of reproductive age for IPV (grade B) but did not find sufficient evidence to suggest for/against screening older adults or vulnerable adults. Various screening tools are available for HCPs. There is no preference for a single instrument but rather a consistent pattern of patient screening with an organizational culture of trauma awareness. Privacy should be provided when screening for violence (Assessment Technologies Institute [ATI], 2023a).

 

Medical interpreters (MIs) should be covered/reviewed with HCPs as a component of cultural competency training. It is especially pertinent when screening for IPV in those patients who do not speak English as their first language. The HCP should assess whether an MI is needed and discuss it with the patient to ensure they consent to the use of an MI. HCPs should brief the MI before the appointment regarding the most crucial aspects before the patient arrives to ensure the efficient transfer of information. When using an MI, it is important to remember the following (Potter et al., 2023):

 

• MIs utilize conduit-style interpretation, a literal translation delivered in the first person without clarification, summarization, or omission.
• HCPs should speak in short sentences and avoid extensive medical jargon except when necessary.
• HCPs should sit across from the patient at eye level and speak directly to the patient, allowing a clear and unobstructed view of the patient and the HCP by the MI.
• When doing a physical examination, a curtain should protect the patient's privacy while allowing the MI to hear and continue interpreting during the examination.
• A short debrief with the MI following the examination should occur, thanking them for their assistance; the medical record should include the MI's name and any other prudent agency contact information.

 

The Humiliation, Afraid, Rape, Kick (HARK); Hurt/Insult/Threaten/Scream (HITS); Extended-Hurt/Insult/Threaten/Scream (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST) are validated screening tools to assess for DV and SV. The HARK has four questions assessing for emotional and physical abuse in the past year. The HITS has four items that determine the frequency of IPV, and the E-HITS includes additional SV-related issues. The PVS has three questions that assess for physical abuse and the safety of the individual. The WAST assesses for physical and emotional IPV via eight questions (ATI, 2023; USPSTF, 2018, 2019).

 

A concerted effort should be made to conduct screening for DV and SV in private, which may be difficult with children, people with disabilities, and other vulnerable populations who depend on caregivers for transport and assistance within the healthcare system. Language barriers or other communication disabilities should also be considered, such as blindness or hearing impairment. Privacy allows the survivor to respond to screening questions without fear of retaliation. In addition to using a screening tool(s), HCPs should assess for the physical and emotional signs of abuse. The Health Resources and Services Administration Strategy to Address Intimate Partner Violence directs health centers across the country to build partnerships with local DV/SV programs; implement new/updated policies to prevent, identify, and care for DV/SV survivors in collaboration with local DV/SV programs; adopt the evidence-based intervention to educate patients on the connection between IPV and their health to promote wellness and safety; train providers/staff regarding the impact of DV/SV on health outcomes and how to assess/care for survivors of DV/SV; and evaluate and sustain progress through diligent quality improvement (National Health Resource Center on Domestic Violence, 2017, p. 3). Reciprocally, with partnerships in place, survivors of DV/SV who seek assistance at a local DV/SV program can then be connected with health clinic staff and resources to obtain the medical care they may need. The evidence-based method for screening and brief counseling patients regarding DV/SV advocated in this program is the CUES intervention:

 

• Confidentiality- patients should be seen alone for at least a portion of their visit, and the HCP’s limits of confidentiality should be disclosed before discussing IPV
• Universal education and Empowerment- discuss with all patients about healthy and unhealthy relationships and the effects of violence; at least two FUTURES’ safety cards should be given (one for a friend)
• Support- discuss a patient-centered care plan to encourage harm reduction, make a warm referral to the local DV/SV program partner, and document the disclosure to follow up at the next visit (National Health Resource Center on Domestic Violence, 2017, p. 9)

 

Despite being asked directly by an HCP about violence, survivors may choose not to disclose due to distrust or fear of subsequent violence. A study based on survivors’ advice suggests that the HCP alleviates the patient’s suspicions and stigma by explaining why they are asking. They also recommend creating a supportive and safe atmosphere and providing information and access to resources regardless of disclosure. The act of asking about IPV raises awareness, educates, and transmits compassion (National Health Resource Center on Domestic Violence, 2017).

 

Adolescents can be screened using the Conflict Tactics scale. This scale was developed in 1972 based on the conflict theory. It examines specific acts or events in a conflict and considers that abusers seek power and control over the victim (Ronzon-Tirado et al., 2019).

 

Women of reproductive years have the highest prevalence of IPV, leading to unintended pregnancies, pregnancy complications, STIs, and other gynecological disorders and injuries related to IPV. An excellent opportunity exists for gynecologists and other women’s HCPs to assess, intervene, and provide resources for female patients experiencing IPV. It is important to screen all patients at various times throughout pregnancy because many women do not disclose DV the first time they are questioned about it. IPV screening and counseling should be part of all women's preventative health and obstetric care. For pregnant patients, an assessment should occur at least once per trimester and again during the postpartum visit (ACOG, 2022).

 

Establishing Trauma-Informed Care for DV/SV Survivors

 

A systematic review of TIP concerning DV revealed that while many organizations have worked to identify abuse survivors, there is less agreement on the best interventions for DV programs. The following six principles emerged within the study:

 

• establishing emotional safety
• restoring choice and control
• facilitating connection
• supporting coping
• responding to identity and context
• building strengths (Wilson et al., 2015)

 

Within these six principles, establishing emotional safety includes creating a physical environment that minimizes triggers. For example, this might consist of an area for children to play or a comfortable waiting area with minimal stimulation. Staff should have a nonjudgmental approach to all interactions, including all questions asked. Programs should have well-developed policies related to TIC and communicate these policies clearly and effectively to all staff involved (Wilson et al., 2015).

 

Restoring choice and control allows the survivor to tell their "story" in their way within the time and space they choose. One study described this as helping "clients feel like it is their choice whether or not they share their story and telling their story is a choice, not a problem". In contrast to a consistent "one-size-fits-all" methodology, allowing clients to make choices can help fuel their perception of being in control of their healing (Wilson et al., 2015).

 

Facilitating connection also supports healing by encouraging the survivor to connect with staff, other survivors, their families, and friends in the community. One of the most challenging aspects of this particular skill for staff is learning to interact with the survivor and form mutual relationships (Wilson et al., 2015).

 

Supporting coping validates the survivor's style of coping without judgment. There is no specific way for a survivor to move through healing; this step facilitates progress without dictating how it is done. The survivor should understand that their response to the trauma is appropriate as long as it is helping them move through the healing process (Wilson et al., 2015).

 

Responding to identity and context may facilitate DV survivors accessing available services. A lack of cultural inclusivity often retraumatizes survivors and prevents them from feeling safe. Most importantly, this step allows the survivor to understand what happened to them. The questions are designed to prompt the survivors to look within themselves and consider who they are and what happened during the abusive events (Wilson et al., 2015).

 

Potential areas for building strength within TIC include improving how providers and nurses discuss the initial trauma, cultural competency, and survivor empowerment. While many organizations provide an optimal culture of care for DV and SV survivors, gaps were identified in these areas within the systematic review (Wilson et al., 2015).

 

Similarly, the SAMHSA (2022) outlines its own six key principles of a trauma-informed approach:

 

• safety
• trustworthiness and transparency
• peer support
• collaboration and mutuality
• empowerment, voice, and choice
• cultural, historical, and gender issues (SAMHSA, 2022, para. 3)

 

Barriers to delivering TIC may be within an individual or an organization. One potential individual barrier is a lack of confidence in confronting survivors about their experiences. HCPs have reported fears of offending survivors when asking screening questions. Identification of this fear further supports the need for a culture where assessment for DV and SV is universal and not isolated to those perceived to be at risk. Consistently, nurses cite a lack of training as a barrier to screening for DV and SV. Additional training, with opportunities for role-play or simulation, will allow for increased comfort and confidence when addressing these issues with patients. Institutional barriers may include a lack of time, perceived powerlessness to help, or marginalization by colleagues or the organization. Improved identification of abuse can be achieved through increased training, robust policies and procedures, and an expectation of universal screening of all patients (ACOG, 2022).

 

If an HCP determines that a patient is a victim or survivor of violence, they should acknowledge the trauma and assess the immediate safety of the patient and any children involved. A safety plan using local resources specific to their area is essential. The survivor should be given information on mental health services, crisis hotline numbers, rape relief centers, shelters, legal aid, and police contact information. It is incumbent upon each HCP to have this information prepared in advance or to be able to access it quickly if needed. The survivor should not be forced to accept assistance, and information should not be placed in their pocket or purse without their knowledge, as the perpetrator may find this information and escalate the violence. This mandate also further diminishes the survivor’s sense of control and autonomy. It is optimal to offer a private phone call for the survivor to connect with a local DV agency, shelter, or the National Domestic Violence Hotline. Particularly if the survivor needs an interpreter, the National Domestic Violence Hotline is multilingual and can support survivors whose primary language is not English. Since an abusive partner may monitor the survivor's call logs, their personal phone should not be used (National Domestic Violence Hotline, n.d.).

 

Mandatory Reporting

 

State and local reporting requirements vary by jurisdiction, and the nurse, physician, or HCP should be familiar with their local and state expectations. Any known or suspected violence against vulnerable populations must be reported in the United States, although specific regulations will vary by state. Vulnerable individuals include children, older adults, and those who are mentally disabled. Failure to report suspected abuse can lead to hefty fines or incarceration for the nurse or other HCP. Most states require that injuries caused in violation of criminal law by intentional or non-accidental means or involving the use of a weapon be reported to the proper authorities. To ensure compliance with state and federal laws related to reporting, local law enforcement or DV agencies can help guide the nurse or HCP to specific jurisdictions (Thomas & Reeves, 2023). HCPs should be aware of the reporting requirements in their state.

 

Reporting suspected abuse of a child is mandatory in all states. Child abuse and neglect must be reported to the relevant local and/or state department if there is reasonable cause to believe a child may be suffering physical or emotional abuse by specified mandated reporters in 47 states and the District of Columbia; the remaining three states, Indiana, New Jersey, and Wyoming, require all persons to report regardless of profession. Reporting should include harm or substantial risk of harm to a child's health or welfare, sexual abuse, neglect, malnutrition, or physical dependence on a drug at birth (Child Welfare Information Gateway, 2019). Reporting may also be required for incidents involving older adults or persons with disabilities in many states. However, adult reporting of DV is controversial. Most states do not mandate reporting of DV in adults as it could escalate the violence. Additional acts of violence may require reporting (ACOG, 2022).

 

Human Trafficking

 

                Human trafficking is considered a violent crime and should be addressed when discussing DV and SV. Human trafficking is modern slavery and may take the form of labor trafficking or sex trafficking. It is characterized by exploiting an individual with force, fraud, or coercion to either work or perform sexual acts. Risk factors for human trafficking targets include living in unsafe situations, poverty, members of vulnerable populations, or those in an environment of abuse at home. Sex trafficking affects the survivor's health, including increased risk for HIV/AIDS, STIs, pelvic pain, rectal trauma, or urinary difficulties. Potential long-term consequences for survivors of sex trafficking also include pregnancy secondary to rape or prostitution; infertility related to chronic, untreated STIs or unsafe abortions; infections or mutilations caused by sex trafficker's "doctors"; chronic back pain; malnourishment; dental problems; diabetes; cancer; or infectious diseases such as tuberculosis. Physical signs of abuse, such as bruises, bites, and scars, may be present. The injuries may be in areas that are not readily seen, such as the lower back. Substance use is common in sex workers as they may be forced to take them by their perpetrators or use them voluntarily to cope with the situation. Mental health issues such as depression, panic attacks, shock, denial, or shame are common among survivors of human trafficking (CDC, 2022f).

 

 There has been an increased awareness of human trafficking in recent years. The Trafficking Victims Protection Act was originally developed in 2000 by President Bill Clinton to train and outline services needed for survivors of human trafficking; it was reauthorized in 2017 to expand resources and further address the needs of survivors. Prevention efforts should emphasize encouraging healthy relationships, fostering safe homes and neighborhoods, identifying vulnerabilities during healthcare visits, reducing the demands for commercial sex, and ending business profits from trafficking-related transactions (CDC, 2022f).

 

PTSD and Domestic Violence

 

The long-term effects of DV and SV may include PTSD. The American Psychiatric Association (2022) defines PTSD as "a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, serious accident, terrorist act, war/combat, rape or other violent assault." Those experiencing PTSD have distressing thoughts and feelings toward their experience that last long after the event is over. The individual could experience flashbacks, nightmares, sadness, fear, anxiety, anger, poor interpersonal relationships, or attachment issues. A person with PTSD can have strong adverse reactions to loud noises or accidental touch. Symptoms of PTSD have four categories: intrusive thoughts, avoiding reminders, negative thoughts and feelings, or arousal and reactive symptoms. To be diagnosed with PTSD, these symptoms should be exhibited for over a month and may persist for years. PTSD may occur with other mental health conditions, such as depression or substance use disorder (American Psychiatric Association, 2022).

 

              Anyone impacted by DV or SV can develop PTSD, and in most cases, the condition is complex. The factors related to PTSD in DV and SV survivors can include:

 

• feelings of guilt related to the violence
• the age of the survivor
• the duration of the trauma or abuse
• the survivor’s perception of the trauma
• a lack of social support
• an inability to stop the abuse or violence (Lacasa et al., 2018)

 

PTSD can also occur from perceived threats, and early recognition can avoid many of the long-term implications of PTSD. Children who are survivors of DV or SV do not respond well to the standard treatment of reliving their experience during therapy. This group responds best to emotional regulation and group therapy that allows them to discuss their feelings. Adults with a history of abuse as children may also benefit from this treatment. A multi-faceted approach to caring for survivors of DV and SV with PTSD is vital to promote safety, self-care, and protection from further violence (Lacasa et al., 2018).

 

National Resources:

 

• National Domestic Violence Hotline-

 

• Call (800) 799-7233

 

• Text START to 88788

 

• Visit www.thehotline.org

 

References

American College of Obstetricians and Gynecologists. (2022). Intimate partner violence. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2012/02/intimate-partner-violence

American Psychiatric Association. (n.d.). Domestic violence. https://www.psychiatry.org/patients-families/domestic-violence

American Psychiatric Association. (2022). PTSD. https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

American Psychological Association. (2022). Trauma. https://www.apa.org/topics/trauma

Assessment Technologies Institute. (2023a). RN Engage community health. www.atitesting.com.

Assessment Technologies. (2023b). RN Engage maternal newborn. www.atitesting.com

Brem, M. J., Florimbio, A. R., Elmquist, J., Shorey, R. C., & Stuart, G. L. (2018). Antisocial traits, distress tolerance, and alcohol problems as predictors of intimate partner violence in men arrested for domestic violence. Psychology of Violence, 8(1), 132–139.

The Center for Healthcare Strategies. (n.d.) What is trauma-informed care? Retrieved September 11, 2023, from https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/

Center for Social Justice. (2022). Why are men often overlooked as victims of domestic abuse? https://www.centreforsocialjustice.org.uk

The Centers for Disease Control and Prevention. (2021a). Elder abuse. https://www.cdc.gov/violenceprevention/elderabuse/index.html

The Centers for Disease Control and Prevention. (2021b). Risk and protective factors. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/riskprotectivefactors.html

The Centers for Disease Control and Prevention. (2022a). Preventing child abuse and neglect. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html

The Centers for Disease Control and Prevention. (2022b). Preventing intimate partner violence. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html

The Centers for Disease Control and Prevention. (2022c). Preventing sexual violence. https://www.cdc.gov/violenceprevention/sexualviolence/fastfact.html

The Centers for Disease Control and Prevention. (2022d). Preventing youth violence. https://www.cdc.gov/violenceprevention/youthviolence/fastfact.html

The Centers for Disease Control and Prevention. (2022e). Public health approach to violence. https://www.cdc.gov/violenceprevention/publichealthissue/publichealthapproach.html

The Centers for Disease Control and Prevention. (2022f). Sex trafficking. https://www.cdc.gov/violenceprevention/sexualviolence/trafficking.html

The Centers for Disease Control and Prevention. (2023). Preventing teen dating violence. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/teendatingviolence/fastfact.html

Child Welfare Information Gateway. (2019). Mandatory reporters of child abuse and neglect. https://www.childwelfare.gov/pubPDFs/manda.pdf

Child Welfare Information Gateway. (2021). Child witnesses to domestic violence. https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/witnessdv/

Criminal Justice Research. (n.d.). The rule of thumb and domestic violence. Retrieved September 11, 2023, from http://criminal-justice.iresearchnet.com/crime/domestic-violence/rule-of-thumb/.

The Domestic Abuse Intervention Programs. (n.d.). The Duluth model: Power and control wheel. https://www.theduluthmodel.org/wheels/

Elkins, J., Crawford, K., & Briggs, H. (2017). Male survivors of sexual abuse: Becoming gender-sensitive and trauma-informed. Advances in Social Work, (1), 116. https://doi.org/10.18060/21301

Evans, M., Lindauer, M., & Farrell, M. (2020). A pandemic within a pandemic: Intimate partner violence during Covid-19. The New England Journal of Medicine. https://doi.org/10.1056/NEJMp2406

Hardy, A., & Rice, K. (2016). Violence and residual associations among Native Americans living on tribal lands. The Professional Counselor, 6(4), 328-343.

HelpGuide. (2023). Domestic violence and abuse. https://www.helpguide.org/articles/abuse/domestic-violence-and-abuse.htm

Indu, P. (2018). Mental health implications of elder abuse and domestic violence. Indian Journal of Psychological Medicine, 40(6), 507–508. https://doi.org/10.4103/IJPSYM.IJPSYM_438_18

Lacasa, F., Álvarez, M., Navarro, M. Á., Richart, M. T., San, L., & Ortiz, E. M. (2018). Emotion regulation and interpersonal group therapy for children and adolescents witnessing domestic violence: A preliminary uncontrolled trial. Journal of Child & Adolescent Trauma, 11(3), 269–275. https://doi.org/10.1007/s40653-016-0126-8

Mueller, I. & Tronick, E. (2019). Early life exposure to violence: Developmental consequences on brain and behavior. Frontiers in Behavioral Neuroscience, 13, 156. https://doi.org/10.3389/fnbeh.2019.00156

National Coalition Against Domestic Violence. (n.d.). Statistics. Retrieved September 9, 2023, from https://ncadv.org/statistics

National Coalition of Anti-Violence Programs. (2018). Lesbian, gay, bisexual, transgender, queer, and HIV-affected hate and intimate partner violence in 2017. https://avp.org/2017-hv-ipv-report/

National Conference of State Legislatures. (2019). Domestic violence/domestic abuse definitions and relationships. http://www.ncsl.org/research/human-services/domestic-violence-domestic-abuse-definitions-and-relationships.aspx

National Domestic Violence Hotline. (n.d.). Abuse in immigrant communities. https://www.thehotline.org/resources/abuse-in-immigrant-communities/

National Health Resource Center on Domestic Violence. (2017). Prevent, assess, and respond: A domestic violence tool-kit for health centers & domestic violence programs. http://ipvhealthpartners.org/wp-content/uploads/2018/08/IPV-Health-Partners-Toolkit-8.18.pdf.

National Library of Medicine. (2023). Prevalence and Correlates of Intimate Partner Violence During COVID-19: A Rapid Review. Ncbi.nlm.nih.gov/pmc/articles/PMC8961087/

National Network to End Domestic Violence. (n.d.). Domestic violence, housing, and homelessness. https:nnedv.org/wp-content/uploads/2019/07/Library_TH_2018_DV_Housing_Homelessness.pdf

National Resource Center on Domestic Violence. (2013) Domestic violence victims/survivors: Defining the problem and the population. https://www.nrcdv.org/rhydvtoolkit/each-field/violence-victims/define.html

Newman, C. (2021). The pandemic is increasing intimate partner violence. Here is how healthcare providers can help. https://www.uab.edu/news/health/item/12390-the-pandemic-is-increasing-intimate-partner-violence-here-is-how-health-care-providers-can-help

Petrosky, E., Blair, J., Betz, C., Fowler, K., Jack, S., & Lyons, B. (2017). Racial and ethnic differences in homicides of adult women and the role of intimate partner violence. Morbidity and Mortality Weekly Report, 66(28), 741-746. https://doi.org/10.15585/mmwr.mm6628a1

Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2023). Fundamentals of nursing (11^h ed.). Elsevier

Ronzon-Tirado, R. C., Munoz-Rivas, M. J., Zamarron-Cassinello, M. D., & Rodrigue, N. R. (2019). Cultural adaptation of the modified version of the conflicts tactics scale (M-CTS) in Mexican adolescents. Frontiers in Psychology, 10(619) 1-9. https://doi.org/10.3389/fpsyg.2019.00619

Rural Health Information Hub. (2021). Violence and abuse in rural America. https://www.ruralhealthinfo.org/topics/violence-and-abuse

SafeHouse Center. (2019). The intersection of domestic violence and poverty. Safehousecenter.org/the-intersection-of-domestic-violence-and-poverty

Stockman, J. K., Hayashi, H., & Campbell, J. C. (2015). Intimate partner violence and its health impact on disproportionately affected populations, including minorities and impoverished groups. Journal of Women's Health, 24(1), 62–79. https://doi.org/10.1089/jwh.2014.4879

Substance Abuse and Mental Health Services Administration. (n.d.). Intimate partner violence. Retrieved September 8, 2023, from https://www.integration.samhsa.gov/clinical-practice/intimate-partner-violence#Providers

 Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. https://youth.gov/feature-article/samhsas-concept-trauma-and-guidance-trauma-informed-approach

Substance Abuse and Mental Health Services Administration. (2022). Trauma and violence. https://www.samhsa.gov/trauma-violence

Thomas, R., and Reeves, M. (2023). Mandatory reporting laws. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK560690/

US Department of Justice. (2023). Domestic violence.

https://www.justice.gov/ovw/domestic-violence

US Preventive Services Task Force. (2018). Intimate partner violence, elder abuse, and abuse of vulnerable adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and
vulnerable-adults-screening

World Health Organization and the United Nations Entity for Gender Equality and the Empowerment of Women. (2020). Violence against women and girls data collection during Covid-19. https://www.who.int/publications/m/item/vawg-data-collection-during-covid-19

Wilson, J. M., Fauci, J. E., & Goodman, L. A. (2015). Bringing trauma-informed practice to domestic violence programs: A qualitative analysis of current approaches. American Journal of Orthopsychiatry, 85(6), 586-599. http://dx.doi.org/10.1037/ort0000098.

 Yakubovich, A. R., Stöckl, H., Murray, J., Melendez-Torres, G. J., Steinert, J. I., Glavin, C. E., & Humphreys, D. K. (2018). Risk and protective factors for intimate partner violence against women: Systematic review and meta-analyses of prospective-longitudinal studies. American Journal of Public Health, 108(7), e1–e11. https://doi.org/10.2105/AJPH.2018.304428